Eleanor Brabant

1. 1. lack of clear observation policy implementation

   “It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable patients.”

2. 2. failure to safeguard vulnerable patients from crime

   “Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as [the deceased] and their responsibility to report those crimes to the police, whether or not the patient consented.”

3. 3. inability to detain informal patients

   “It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances.”

4. 4. uncertainty in family involvement when consent withdrawn

   “It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented, and further training appears to be necessary.”

No published response was found on judiciary.uk.