Gerard Murray
1 Sept 2023 · Coroner Elizabeth Didcock · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. limited risk assessment and risk management plan
“limited risk assessment and risk management plan documented for [the deceased] on ward B2 now Beech ward”
2. inadequate door board system for monitoring the return of patients after unescorted leave
“inadequate door board system for monitoring the return of patients after unescorted leave on ward B2”
3. limited family and carer involvement in care plan and ward rounds
“extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
4. limited awareness of ligature risk reduction pathway
“limited awareness of the ligature risk reduction pathway by staff on B2 now Beech ward”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
Later report
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”
Responses
2023-0391-Response-from-Nottingham-Heathcare.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
Stated action
“To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”
Stated action
“an electronic device is being procured which will allow multiple alarms to be set for each person's leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot.”
Stated action
“To ensure there is consistent compliance with the door board system, a checking process has been incorporated in the Senior Nurse's daily observation spot checks. This includes a band 6 nurse or above observing staff completing their observations rounds, and quality checking their understanding and performance within the role.”
Stated action
“The Triangle of care process has also been strengthened as part of our ongoing quality improvement plans. Our Quality Standards Team also undertake reviews of Care Plans and look for clear evidence that these plans are produced with the patient, family and carers.”
Stated action
“all-acute wards have recruited a Carer Peer Support worker whose working week is dedicated to liaising with patients and their families/carers and ensuring the link with MDT members, and clinical discussions is strong.”
Stated action
“It is foreseen that the Policy will recommend that clinical teams will receive training in the clinical risk assessment tools employed by each service, The training will be sourced from external providers or developed with the learning and development team to make sure that the learning materials reflect the Policy requirements and the individual needs of the people that we support.”