Neil Challinor-Mooney

20 May 2021 · Coroner Nadia Persaud · East London

The coroner's concerns

1. risk assessment and risk management not followed
“The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear, however the Court was not fully satisfied that the said policy had been fully embedded into practice. A number of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy.”
2. electronic records integrity compromised
“The Inquest heard that medical records should be validated very shortly after being entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after [the deceased] had passed away, but these were not apparent on the records disclosed to the Court.”
3. removal and return of trainers without documentation
“[the deceased] suffered an acute relapse in his mental health in late October 2018. He required admission to hospital under the provisions of the Mental Health Act on the 1st November 2018. Shortly after his admission to hospital, his trainers were removed from him as part of risk management. There was no documentation around the removal of the trainers. At some point during the course of admission to hospital (1s November to 16" November 2018) [the deceased]'s trainers were returned to him.”