Jack Portland

1. 1. lack of communication to family about leave changes

   “The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also fo the family of a patient along with the Inpatient clinical team and the MHA administrator. The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr [name redacted] S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient. The family”

2. 2. incorrect whiteboard entry leading to delayed identification of absence

   “A specific request for leave from the patient would be actioned by a nursing-level assessment, authorisation of the specific leave by the nurse in charge and implementation of the leave by a staff member. A Record of Leave of Absence would be completed and signed by the patient and the staff member and that staff member would usually then write up that patient's name and the times out and due back on a whiteboard in the office. Evidence from witnesses confirmed that there was no particular order”

3. 3. inconsistent observation chart completion

   “The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave.”

4. 4. inadequate AWOL procedure and documentation

   “The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr [name redacted] AWOL.”

5. 5. failure to update risk assessment with relevant history

   “Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr [name redacted] time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr [name redacted] time at HMP Woodhill. lt was acknowledged in evidence”

6. 6. delayed and inaccurate RCA reports

   “The actions taken in relation to the preparation of two Root Cause Analysis reports were of concern in that the first RCA was founded on inaccurate information and the second RCA still contained inaccuracies and was not completed until some 11 months after the fatal event. The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports.”

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