Benjamin Popovach
23 Oct 2020 · Coroner Ian Arrow · Plymouth, Torbay and South Devon
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. risk assessments not completed for patients on leave
“At Page 20 of the Root Cause Analysis there is an outcome of the review listed under Immediate Changes - Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan Sharing the learning - To be shared with Ward Staff and Community Teams”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
This report
“Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan”
Responses
2020-0214-Response-from-Devon-Partnership-NHS-Trust-Redacted.pdf ↗· Devon Partnership NHS Trust
Stated action
“Immediate changes Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in a plan.”