Yuksel Ismail
25 Aug 2022 · Coroner Emma Whitting · Bedfordshire and Luton
The coroner's concerns
1. mental health patients transferred without adequate risk assessment
“the current transfer policy needs reviewing...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient”
2. lack of Mental Capacity Act training for transfer staff
“There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department”
3. inadequate restraint policy for mentally incapacitated patients
“Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the restraint is necessary to preserve life or health and is proportionate to risk”
4. lack of PLS staff involvement in transfer risk assessment
“the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements”
5. patients leaving emergency department without supervision
“PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment”