Eliot Harris
22 Aug 2022 · Coroner Jaqueline Lake · Norfolk
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of observation compliance
“Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of [the deceased] in accordance with NSFT's Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly.”
2. unclear task allocation
“On the night of [the deceased]'s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks - they were told to”
3. inadequate meeting documentation
“Multi Team Meetings were not fully and properly recorded in the clinical records”
4. outdated care plan
“[the deceased]'s Care Plan was not up to date at the time of his death”
5. delayed room entry
“Staff were reluctant to enter [the deceased]'s room following concern for his wellbeing”
6. unclear physical health check process
“It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
This report
“It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out”
Closely relatedConfidence 0.92 · high
Earlier report
“It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient.”
This report
“Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of [the deceased] in accordance with NSFT's Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly.”
Responses
2022-0260-Response-form-Norfolk-and-Suffolk-Foundation-Trust-.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action · three months
“The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse- in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. [name redacted] to this aspect the trust is formulating a seminar on shift co-ordination and”