Neil Carter
5 Mar 2014 · Coroner Sean Cummings · London (West)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate nursing observations
“There were repeated failures to perform basic nursing observations”
2. deliberate falsification of nursing records
“There was a deliberate falsification of the nursing record”
3. inadequate staffing and skill mix
“heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge's authority authority. Management was informed of some issues but failed to listen or act”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“There were repeated failures to perform basic nursing observations”
Later report
“The system of observations carried out within the unit, particularly at night is in need of reform.”
Responses
2014-0103-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“We will also outline proposed developments in the Commission's regulatory functions across Mental Health Services more generally. Before doing so, however, we set out below an overview of the Commission's recent regulatory action in relation to The Priory Hospital Roehampton.”
2014-0103-Response-by-Priory-Group.pdf ↗· The Priory Group
Stated action
“In response to points one and three, | understand that the records falsification and a number of key missing observations in Mr [name redacted] case for the afternoon he absconded from the ward, fell to one nurse, | am informed that the relevant individual was disciplined through Priory's internal processes and dismissed from employment. She was also referred to the NMC as her actions fell short of the standard required.”