Delwyn Preece

“There were consistent and repeated incidents (13 incidents in 6 days) where leave from the ward was granted without any documented mental state examination or risk assessment being undertaken prior to the patient being permitted to leave the ward.”

“There was poor documentation throughout the medical records with entries lacking detail, being added retrospectively (up to two days later) without any explanation or referencing the retrospective nature of the entry.”

“The Patient Safety Incident Investigation authors were unfamiliar with the medical records system which lead to the retrospective entries not being identified correctly, therefore the investigation did not make any finding. However, with more understanding, it is likely the retrospective entries in the medical records who have been identified and their relevance realised which would have altered the content and findings of the report.”