Katy Samuels
11 Dec 2020 · Coroner Delroy Henry · Coventry
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. patient leaving hospital without escort
“The policy is targeted at inpatient and community staff”
2. lack of clear guidance for escorted leave
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient”
3. unverified escort identity and unknown departure time
“The circumstances of this inquest touching upon the death of [the deceased] accentuated this point.”
4. insufficient handover time for escorted leave
“staff handovers are vital and therefore time to enable the same very important.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment”
Later report
“Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave.”
Responses
2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted.pdf ↗· Coventry and Warwickshire Partnership NHS Trust
Stated action
“The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation”