Recent repeats

“some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person”

“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment. Even where call handlers have real concerns that someone not returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same if the individual's address has not been visited, even when told that they would not go there.”

“I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity.”

“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”

“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth”

“it is a matter of concern that in December 2010 only one of four officers were first aid trained and in February 2012 one was still untrained”

“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”

“None of the Carers employed at Hibiscus House had any training in CPR.”

“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted”

“At HMP Haverigg there was inadequate mental health cover with at times only one mental 1 health nurse and no provision for psychiatric referral”

“Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends.”

“The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have and not all appropriate individuals were invited to the reviews.”

“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”

“Failure to carry out ACCT observations recorded in the ACCT log”

“serious difficulty in the recording, communication, and use of ACCT documentation”

“Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-‐‐going training in the ACCT procedure.”

“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”

“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.”

“The inquest heard that Mr [name redacted] could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd 1 October because of the challenges of finding a suitable EMI placement for him.”

“No evidence was seen that recipients of a 'Claires Law' Domestic Violence Disclosure are treated as being of greater vulnerability”

“The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations.”