Matthew Llewellyn-Jones
25 Oct 2016 · Coroner Lydia Brown · Exeter and Greater Devon
The coroner's concerns
1. locked door breaches
“the "locked door" is still being breached on occasion, as identified on audit”
2. unpredictable observations
“Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular”
3. mandatory carer information not captured
“A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and/or family mandatory on admission”
Responses
2016-0385-Response-by-Devon-Partnership-NHS-Trust.pdf ↗· Devon Partnership NHS Trust
Stated action · 10/2/17
“The Entry and Exit Policy is under review, it will be revised to support a 'locked door' policy with a clear expectation of how to ensure that the restriction in movement does not impact on individual's right to exit. It is anticipated that policy ratification will be sought at Senior Management Board on 10/2/17”
Stated action · within the next month
“LED signs for doors have been ordered and we are waiting for them to be delivered and installed. These are due to be installed within the next month”
Stated action · January 2017
“The revised policy will be published in January 2017 across the Trust and will be shared directly with colleagues in the Adult Directorate in its Directorate Bulletin in January 2017”
Stated action
“The form used for recording observations had been changed at the time of the inquest and now requires the specific time of observation to be recorded on the form for each patient”
Stated action · end of February 2017
“A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and / or family mandatory on admission”