Ryan Chapman
31 Jan 2014 · Coroner Penelope Schofield · West Sussex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of understanding of leave policy
“lack of understanding by staff of the Trust's Leave for Non detained patients Policy”
2. uncertainty about policy application to internal activities
“Staff seemed unclear as whether or not this policy should be applied when patients left the ward to attend activities within the hospital grounds”
3. confusion about peer support worker role
“Staff appeared to be unclear as to the role of a Peer Support worker with regards to whether or not they are able to fulfil the role of an escort for patients leaving the ward”
4. delayed risk assessment and care plan
“[the deceased]'s Risk assessment and Health Care Plan was not completed within the required period”
5. insufficient family information on admission
“lack of written information provided to families by the Hospital on admission to help them support their family member”
6. inadequate ward visitor security
“There appeared to be a general lack of security on ward with regards to visitors”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“During the course of the evidence it was shown that there a lack of understanding by staff of the Trust's Leave for Non detained patients Policy.”
Later report
“I am concerned that s17 leave is being authorised by staff in ignorance of the leave conditions. In this particular case, the responsible clinician granted leave on the 13th of February 2025, a condition being that [the deceased] had to test negative for drug use before leave was allowed.”
Responses
No published response was found on judiciary.uk.