Rebecca Begg

8 Dec 2021 · Coroner Dr Elizabeth Didcock · Nottinghamshire

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

1. non‑compliance with care plans and insufficient incident review
“Failure to monitor compliance with care plans, and a lack of robust incident reviews - whilst welcome changes are planned with improved audit and monitoring, this is not yet fully implemented”
2. untested observation level support plans
“As yet untested 'observation level' support plans”
3. exclusion of support workers from regular client meetings
“A lack of inclusion of support workers in regular meetings about clients- it is these staff working each day with clients, that can contribute to progress review, and if necessary to a change in the support plans and/or risk assessments”
4. insufficient staff time to review care plans
“No dedicated time for staff to read and digest care plans”
5. unclear authority to strip rooms after self‑harm incidents
“Lack of clarity regarding who can instruct for a room to be stripped following an incident of serious self harm”
6. absence of formal escalation pathway to NHS Trust
“Lack of a system for formalised contact with Nottinghamshire Healthcare NHS Foundation Trust (NHCT), including if Heathcotes are unhappy about the response from the Mental Health teams, a means of escalation to NHCT senior team”

Raised again laterRonald Nelson15 Jan 2026 · 4 years 1 month later

Closely relatedConfidence 0.90 · high

This report

“Failure to monitor compliance with care plans, and a lack of robust incident”

Later report

“There are concerns over the level of compliance of care plans.”