Sarah Shepherd

1. 1. lack of clear referral process to PICU

   “It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient's RIO (or other medical) notes. From the evidence”

2. 2. incorrect resuscitation trigger

   “It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not "breathing" whereas the Council states that it should be started if the patient is not "breathing normally". The evidence heard as to what training the nursing staff had been given concerning when”

3. 3. misleading resuscitation aide memoire

   “Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not "breathing" rather than "breathing normally”

No published response was found on judiciary.uk.