Henry Curtis-Williams
19 Dec 2018 · Coroner Sean Cummings · London (West)
The coroner's concerns
1. lack of contemporaneous notes on suicidal ideation
“following admission to Southgate Ward [the deceased] was seen by a number of different staff members. It became evident that there was a Culture of not recording contemporaneous notes. This was very obvious with reference to recording presence or absence of suicidal ideation”
2. discharge by junior doctors without senior consultation
“patients could be discharged by very junior doctors without prior reference to Consultant or Senior colleagues even though [the deceased] had been admitted after being assessed by 2 Section 12 approved doctors and an Approved Mental Health Professional who felt he needed a prolonged inpatient stay”
3. loss of informal communication records
“Communication between staff members was very informal with no record S kept of important messages relayed. For example, the member of staff who held a one to one meeting with [the deceased] was not present at the ward round where [the deceased]'s case was discussed but said she had verbally passed a message to the ward round nurse. This was normal practice on this ward. There was no record of the message, or of it being passed or that it was considered at the ward round”
Responses
2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action
“the Trust will be using [the deceased]'s case in the provision of learning via our. patient safety newsletter and- through the range of practice * education teams and staff receive. Linked to this, under the leadership of the Medical Director, the Trust is commencing a programme of work to examine the barriers to using 'clinical curiosity' and develop the skills and frameworks for staff to ensure this critical aspect of care is consistently applied”