Francesca Whyatt
21 Aug 2017 · Coroner Karon Monaghan · London Inner (West)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. risk assessment of the configuration of the East Wing ward over four floors
“There has been no risk assessment of the configuration of the East Wing ward over four floors.”
2. lack of written or formal guidance on frequency of ad-hoc agency staff completing observation competency checklist
“There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist.”
3. ligature incidents not automatically treated as SUIs
“Ligature incidents are not automatically treated as SUIs (though the evidence suggests that death can occur within seconds of a ligature being applied).”
4. lack of clear guidance or criteria on circumstances for treating ligature incidents or other self-harming incidents as S
“There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation.”
Later report
“There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment.”
Responses
2017-0248-Response-by-Priory-Hospital_Redacted.pdf ↗· Priory Hospital Roehampton