Jason Bayley

“Mr [name redacted] refused to take at least one of his daily doses of lactulose which he was prescribed as part of a regime of laxatives for constipation. While these refusals were documented in the Electronic Prescribing and Medicines Administration document, there were fourteen occasions when it was incorrectly documented that all medication had been taken under the 'Medication Adherence' section in the Rio notes.”

“I am concerned that accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning. I am concerned that there may be a risk to the life of some patients if staff understand that medication has been taken when it has not.”

“[the deceased] suffered from paranoid schizophrenia and was detained under section 3 of the Mental Health Act 1983 for treatment at St. Andrew's Healthcare. He was prescribed clozapine on a long term basis, which carried a recognised risk of constipation which was treated with a regime of laxatives. Despite this, [the deceased] had chronic constipation which was likely to have been developing over a period of many years. In December 2022 [the deceased]'s severe and chronic constipation led to intestinal pseudo-obstruction”