Melanie Elms
7 Mar 2022 · Coroner Jessica Russell-Mitra · County of Surrey
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate care package
“The care package arranged for [the deceased] following discharge from lengthy in-patient admission was not followed and was altered to something which the treating doctor did not consider adequate”
2. incomplete walk book
“The walk book was not properly completed”
3. lack of extra planning for changes in circumstances
“There was no extra planning for changes in circumstances: [the deceased] faced never being allowed to return to family life with her husband and son due to Child In Need proceedings; changes in medication and less support from family due to the Social Services requirements”
4. missing person plan absent
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave”
5. inadequate risk assessment prior to leave
“Risk assessment prior to leave was not adequate”
6. risk assessment not recorded
“Risk assessment prior to leave was not recorded”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
This report
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave.”
Responses
No published response was found on judiciary.uk.