Emma Butler
12 Apr 2019 · Coroner Crispin Butler · Buckinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. access to self-harm materials
“Access to means of self-harm on the ward”
2. introduction of self-harm items from outside
“Access to means of self-harm from outside the ward”
3. delayed emergency response
“Urgent or emergency access to the ward phone”
4. inadequate discharge planning
“Planning for discharge”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community.”
Later report
“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.”
Responses
2019-0133-Response-by-Oxford-Health-NHS-Trust.pdf ↗· Oxford Health NHS Foundation Trust
Stated action · September 2019
“The Trust is considering if plastic spoons can be replaced by an alternative product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is working with the matrons to identify if there is alternative cutlery available that may be more suitable for this patient group.”