Matthew Caseby
22 Apr 2022 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. inconsistent record keeping
“During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets.”
2. inaccurate clinical records
“There were numerous inaccuracies in [the deceased]'s medical records, eg his status was written as informal when he was formal, he was described as violent when he was not and was described as”
3. inadequate risk assessment updates
“Despite this, and with clear evidence that [the deceased] was at risk of absconsion, his risk assessment was not updated over the weekend when the risk materialised”
4. unsafe courtyard environment
“A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe”
5. lack of standard perimeter fence guidelines
“National guidelines for perimeter fences and security in acute mental health unit outside areas”