Daniel Tucker
29 Feb 2024 · Coroner Michael Wall · Nottingham City and Nottinghamshire
The coroner's concerns
1. lack of ward specific risk assessment and care plan
“A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan”
2. inadequate named nurse allocation and recording
“Inadequate system of allocating a named nurse to patients and recording the same”
3. insufficient skills or knowledge to encourage patient engagement
“Inadequate skills/knowledge/training on how to encourage patients to engage”
Responses
2024-0115-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2024-0115-Response-from-NHS-England.pdf ↗· NHS England
2024-0115-Response-from-Nottinghamshire-Healthcare.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
Stated action · March 2024
“The Trust expectation remains that care plans and risk assessments are individualised and fully updated following the 72-hour assessment period.”
Stated action · ongoing
“It was recognised within the inquest that an urgent review was needed for the system of named nursing within AMH inpatient acute wards.”
Stated action · March 2024
“Mr. [name redacted] had very clear reasons for seeking an alternative bed which may have supported his engagement with the team. Whilst Mr. [name redacted] was recorded on a transfer list seeking an alternative bed this process was no robust enough.”