Harry Vass
13 Jun 2024 · Coroner Maria Voisin · Avon
The coroner's concerns
1. lack of adequate observations for agitated patient
“Due to [the deceased]'s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.”
2. lack of awareness of acute brain disturbance
“It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.”
3. vulnerability to cardiac arrest
“this group are vulnerable to cardiac arrest”
Responses
2024-0324-Response-from-RCN.pdf ↗· Royal College of Nursing
Stated action
“We will respond, as far as we are able to each concern in turn: I. It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.”