Rebecca Romero
13 Dec 2017 · Coroner Maria Voisin · Avon
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. confusion over in-patient transfer forms
“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure”
2. lack of time-specific care plans
“Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so again expectations are managed and everyone knows exactly what the plan is and when actions will occur”
3. inconsistent risk assessment terminology
“That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach”
4. inadequate guidance on staff communication with young persons via text or social media
“consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media.”
5. lack of guidance for out-of-area child psychiatric inpatient care and reintegration
“Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient out of area”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.”
This report
“Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so again expectations are managed and everyone knows exactly what the plan is and when actions will occur.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”
This report
“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure.”
Responses
No published response was found on judiciary.uk.