Georgia Dehaney-Perkins
5 Feb 2024 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. self-harm by ligature
“On 28 August Ms [name redacted] was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm”
2. medication interaction causing increased sedation
“Medication was appropriately withheld on 28 August when Ms [name redacted] returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation”
3. lack of discussion about alcohol medication interaction
“This risk of consuming alcohol with her specific medication was not discussed with the Ms [name redacted] or family”
4. incomplete alcohol consumption recording
“Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated”
5. care plan omissions regarding medication management
“Ms [name redacted] had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September”
6. failure to act on updated risk assessment
“The Home First Treatment Team attended a scheduled appointment on 4 September and Ms [name redacted] appeared stable and updated the risk assessment that the risk of self-harm remained significant when alcohol was consumed”
Responses
2024-0059-Response-from-Essex-Partnership-University-NHS-Foundation-Trust.pdf ↗· Essex Partnership NHS Foundation Trust
Stated action
“All patients have a risk assessment completed within four hours of admission to the ward. This is monitored through the clinical dashboard daily by the Nurse in Charge. On admission the Nurse in Charge will delegate duties to ensure that all admission tasks are completed.”