Alice Gibson-Watt
18 May 2017 · Coroner Sarah Ormond-Walshe · London (West)
The coroner's concerns
1. lack of regular monitoring and documentation of physical vital signs
“that in my opinion means that there is still a risk that future deaths will occur unless action is taken”
2. identification of acutely physically unwell patients
“identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care”
3. absence of regular vital sign monitoring
“no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health”
4. insufficient attention to acute physical deterioration
“identification of patients who are becoming acutely physically unwell does need more attention in general”
5. potential reliance on remote monitoring without staff training
“IT am aware that remote physiological monitoring of patients in acute mental health settings has been trialled”
6. limited availability of Nurse Consultants in Physical Healthcare
“Nurse [name redacted] in Physical Healthcare would be able to assist”
Responses
2017-0163-Response-by-NHS-England.pdf ↗· NHS England
Stated action
“The national Physical Health SMI CQUIN supports the improvement of physical healthcare to reduce premature mortality in peopie with serious mental illness (SMI).”