Alfred Meek
14 Jun 2018 · Coroner Sarah Slater · South Yorkshire (East)
The coroner's concerns
1. poor compliance with Enhanced Care Supervision
“clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments”
2. lack of resources for appropriate supervision
“no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision”
3. systems and procedures for Enhanced Care Supervision
“Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced care Supervision”
Responses
2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust.pdf ↗· Doncaster and Bassetlaw NHS Foundation Trust
Stated action · this year
“The Trust has a strategic approach and focus on preventing falls, with the development of policies, assessment tools and compliance to NICE guidance in respect of falls prevention. As a Trust we are committed to reducing inpatient falls and improving our learning from falls. To facilitate this we have developed a standard Trust action plan which meets the minimum standards we would expect to see after a fall resulting in moderate harm, severe harm or death.”