Kenneth Baylis
4 Mar 2024 · Coroner Elizabeth Didcock · Nottinghamshire
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of family involvement in risk assessment
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning”
2. inadequate suicidal risk assessment
“Inadequate suicidal risk assessment and suicide mitigation”
3. non‑compliance with planned leave policy
“Lack of compliance with the Trusts Planned Leave policy”
4. inadequate incident review and investigation
“Inadequate review and incident investigation following a serious suicide attempt or a death”
5. lack of assurance that corrective actions are implemented
“I am not reassured that necessary actions to address these serious issues identified are in place”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“It is also concerning that there appears to be no timescale for the two requirements referred to above - ie how contemporary does a doctor review and”
This report
“Lack of compliance with the Trusts Planned Leave policy.”
Identical hazardConfidence 0.90 · high
Earlier report
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
This report
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”