Michelle Whitehead
4 Oct 2023 · Coroner Laurinda Bower · Nottingham City and Nottinghamshire
The coroner's concerns
1. inadequate staff knowledge of monitoring requirements after sedative use
“The Trust's Rapid Tranquilisation policy has not been sufficiently embedded through learning and development to ensure that all staff have a good working knowledge of the requirements for safely monitoring patients following the use of sedative medications”
2. unclear response to suspected unconsciousness after sedation
“The Trust's Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring, or is felt to be asleep”
3. policy non‑compliance with national guidance
“The Trust's current policy appears to depart from National guidance - NICE issued Rapid Tranquilisation Guidance in Notice NG10 in May 2015”
4. absence of guidance for managing psychogenic polydipsia
“Psychogenic Polydipsia - there appears to be no guidance, either locally or nationally, on the management of this condition”