Nimo Younis
20 Nov 2019 · Coroner ME Hassell · London Inner (North)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of understanding of police response to AWOL patient
“C&l ward staff did not have a proper understanding of what action the MPS would take in what circumstances, following the report of a patient absent without leave.”
2. lack of understanding of required actions to prompt police progression
“C&l ward staff did not have a proper understanding of what action the MPS required others to take in order to prompt the police to progress the matter further.”
3. lack of practical plan to act
“C&l ward staff did not have a practical plan as to how to take that action with the resources at their disposal.”
4. lack of understanding of required information for police enquiry
“C&l ward staff did not have a proper understanding of what key information they needed to provide the MPS in order to trigger a police missing person enquiry, or to escalate an existing enquiry.”
5. failure to utilise patient's friends for locating
“C&l ward staff did not promptly or fully utilise the significant potential of their patient's friends, who were ultimately the route by which [the deceased] was found, and who would certainly have acted sooner if they had appreciated the lack of action being taken - whatever the reason for that lack of action.”
6. lack of information for MPS decision makers
“The MPS decision makers, particularly the night time duty inspector, did not have all the information that the MPS held when they were making decisions.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“There was a failure by the MPS Missing Person's Unit (Greenwich) to carry out an effective search for [the deceased] as a consequence of the lack of information not shared with the Unit”
This report
“C&l ward staff did not have a proper understanding of what key information they needed to provide the MPS in order to trigger a police missing person enquiry, or to escalate an existing enquiry.”
Closely relatedConfidence 0.90 · high
This report
“C&l ward staff did not have a proper understanding of what action the MPS would take in what circumstances, following the report of a patient absent without leave.”
Later report
“the police would not necessarily attend, even if called direct by a hospital staff member in the street following a patient about whom they are worried.”
Closely relatedConfidence 0.85 · high
This report
“C&l ward staff did not have a proper understanding of what action the MPS required others to take in order to prompt the police to progress the matter further.”
Later report
“You will see from the attached narrative that the jury concluded there was a failure by MPS to implement, disseminate and train relevant staff on relevant policies effectively.”
Responses
No published response was found on judiciary.uk.