Ruairi Stewart
10 Mar 2026 · Coroner Elizabeth Wheeler · Cheshire
The coroner's concerns
1. lack of MDT attendance by named nurse
“The timing of the shifts of the named nurse for the patient meant that she was not able to attend any MDT for the patient over many months and her input was therefore only in writing.”
2. inaccurate written reports to MDT
“The named nurse written reports provided inaccurate information to the MDT, giving a reassuring picture of compliance which is not reflected by the written records.”
3. drug tests not executed as planned
“The MDT made plans for a patient to have drug tests. These were not allocated to an individual to be accountable and were instead allocated to "staff". These tests were not carried out as planned.”
4. improper leave management by non‑s12 doctor
“When the responsible clinician was away for an extended period, leave was managed by a non s12 doctor. There is no contemporaneous documentary evidence of the decision making process by that doctor to reinstate leave as decisions were made outside the formal s17 MHA framework.”
5. unsupported leave suspension without testing
“On at least one occasion leave was suspended due to suspected drug use but no drug test was taken and no search carried out, and there was no documentation indicating that consideration had been given to undertaking these acts.”
6. drug use information omitted from shift handover
“On multiple occasions information about recent drug use was not part of the shift handover notes.”