Gary Richards
9 May 2014 · Coroner Andrew Harris · London (Inner South)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. risk of self harm
“Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others”
2. lack of follow up
“After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented.”
This report
“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded.”
Responses
2014-0212-Response-by-South-London-Maudsley-NHS-Trust.pdf ↗· South London and Maudsley NHS Foundation Trust
Stated action
“The Trust's policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”