Polly Carpenter
28 Oct 2014 · Coroner Elizabeth Earland · Exeter & Great Devon
The coroner's concerns
1. lack of clear Named Nurse system
“The Evidence of Named Nurse system which was in operation at the time of [the deceased]'s death indicated its execution to be somewhat nebulous”
2. improved security measures
“The reduction in AWOLS (absences without leave) is good evidence, that the two pronged approach of ++ engagement with patients on a clinical level and the decision to change the windows out to improve security is working”
3. absence of documented risk assessments
“While | note that Risks Assessments were dynamic and said to be performed regularly there was no written record of them appearing on the RIO and staff appeared to have very little or no knowledge of the levels of risk at the instant in time”
4. failure to record observations and nurse allocations
“The decision not to formaily record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern”
5. inability to audit care processes
“From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed”
6. lack of permanent record culture
“it is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of ail the nursing staff, so patients are looked after in the fullest sense of the word”
Responses
2014-0469-Response-by-Devon-Partnership-NHS-Trust.pdf ↗· Devon Partnership NHS Trust
Stated action
“Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written on these forms. From this the registered nurse on every shift would review the completed forms and provide an update on RiO in the progress notes.”