Sasha Forster
23 May 2019 · Coroner David Reid · Hampshire (Central)
The coroner's concerns
1. failure to collect patient after revoked leave
“SBP staff did not arrange to collect [the deceased] and return her to the ward when her s.17 leave had been revoked”
2. burden on family to retrieve patient
“SBP's reliance on her bringing [the deceased] back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her”
3. miscommunication about revocation leading to unsafe return
“The last such occasion when SBP staff on the ward decided that [the deceased]'s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, [the deceased]'s mother was given to believe that it would be, and again reluctantly agreed to bring [the deceased] back to the ward”
Responses
Sasha-Forster-2019-01692_Redacted.pdf ↗· Department of Health and Social Care
Sasha-Forster-2019-01693_Redacted.pdf ↗· Guildford and Waverley Clinical Commissioning Group
Stated action · 18 July 2019
“I am also under a duty to send the Chief Coroner a copy of your response.”
Sasha-Forster-R2019-01692.pdf ↗· Guildford and Waverley Clinical Commissioning Group
Stated action · 22 May 2019
“The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).”
Sasha-Forster-R2019-01693.pdf ↗· Department of Health and Social Care
Stated action · September 2019
“[SABP] has a legal responsibility to arrange for the return to hospital of patients whose s.17 leave they have revoked. If resources are not provided to allow them to fulfil this legal responsibility, there is a risk that future patients, whose s.17 leave has been revoked and who remain at risk of self-harm or suicide whilst in the community, will find the opportunity to act in such a way as results in their death, whether intentionally or not.”
Sasha-Forster-R2019-01694.pdf ↗· Department of Health and Social Care
Stated action
“we consider that this guidance, when followed, ensures safe prescribing and protects patient safety”
Sasha-Forster-R2019-0169.pdf ↗· Guildford and Waverley Clinical Commissioning Group
Stated action
“The Department therefore expects care providers to ensure that those members of staff involved in the return of a patient following revocation of section 17 leave are aware of their powers and responsibilities towards that patient and that these are applied in a consistent manner.”