Darren Hope
4 Nov 2024 · Coroner Linda Lee · Coventry and Warwickshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate verification of leave conditions
“Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave”
2. inaccessible contact mechanisms
“There may be a lack of accessible or reliable means for service users on unescorted leave to contact the facility if they encounter difficulties”
3. reporting system limitations
“There may be limitations in the reporting system's ability to identify and address substantive issues that directly impact patient safety”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment”
This report
“Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave.”