John Walker
21 Aug 2013 · Coroner Christopher Wilkinson · West Sussex
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. risk care planning for Mr Walker
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor rev”
2. observation level changes without rationale
“revised. There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest that Mr [name redacted] was expressing”
3. delay in declaring missing and informing police
“the hospital's AWOL policy was robust and activated and implemented appropriately, concern was raised by the family with regard to the length of time taken before Mr [name redacted] could be declared missing and the police informed”
4. scalable external fences
“At the time of the incident the fences surrounding the external common areas of the ward were of a scalable height by any patient determined enough to do so. It is accepted that this has been subsequently addressed”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
Later report
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
Closely relatedConfidence 0.90 · high
This report
“concern was raised by the family with regard to the length of time taken before Mr [name redacted] could be declared missing and the police informed.”
Later report
“Need for clear information to be given by hospital staff when making the 999 call to report a patient has gone AWOL”
Responses
2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust.pdf ↗· Sussex Partnership NHS Trust
Stated action
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”