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recurance

Liam Hardy

2 Jul 2014 · Coroner Selena Lynch · London (South)

The coroner's concerns

  1. 1. lack of comprehensive patient history

    “The nurse who assessed [the deceased] after an episode of self harm was unaware of some of the significant events in [the deceased]'s history. She explained that the RiO system (an electronic patient record system used in many Trusts) did not flag up or summarise such events or primary concerns and issues in a single place, and there was insufficient time to read all of the notes (which might be voluminous) before seeing a patient. Had she been aware of the full history her actions may have been different in [the deceased]'s”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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