Jada Monoja

“Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with trust policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment. Further, the evidence was that rather than be completed with an assessment per the indicators set out in the tool”

“if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete and/or out of date, and therefore misleading, information”

“to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent viewer is then likely to be incomplete and misleading”

“the potential benefit of using the tool to establish a point of benchmarking/ comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted (as was the case in this inquest)”

“if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the risk assessment tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost”