Laura Page
28 May 2014 · Coroner Lydia Brown · Leicester City & South Leicestershire
The coroner's concerns
1. failed clinician visits
“The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access key fobs where appropriate.”
2. delayed escalation
“The escalation policy should be reviewed to consider specific time targets for action.”
3. inappropriate welfare check threshold
“The threshold for requesting a welfare check should be reconsidered.”
4. lack of audit of failed visits
“An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared.”
Responses
2014-0254-Response.pdf ↗· Leicestershire Partnership NHS Trust
Stated action
“The Crisis Service Manager is now undertaking a weekly audit check on failed visits to assure compliance in line with the new process, and is monitored through key line performance indicators.”