Paul Perrott
11 Dec 2023 · Coroner Deborah Archer · Plymouth, Torbay and South Devon
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate observation chart documentation
“[the deceased]'s observations charts were not filled out adequately or at all on the date of his death”
2. unclear responsibility for observation chart checks
“There appeared to be a lack of clarity over who was responsible for checking the observation charts ,when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect”
3. lack of awareness of prior suicide risk history
“At least one member of staff was unaware that [the deceased] had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose and that [the deceased] had attempted to take his own life less than 3 months previously in exactly the same way as on 31st July 2020”
4. narrow focus on immediate risk without historical analysis
“Although certain changes to policy and procedures were described to me there still seems to be a focus on risk in the”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Lack of information regarding the Levels of Observations and the persons actually making the observations.”
This report
“[the deceased]'s observations charts were not filled out adequately or at all on the date of his death”
Closely relatedConfidence 0.90 · high
Earlier report
“The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”
This report
“At least one member of staff was unaware that [the deceased] had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose”