Sebastian Davies

1. 1. lack of continuity in hourly observations

   “Evidence was given at the Inquest that there was a system of hourly observation checks on patients in their rooms during the course of a night shift. These consisted of shining a torch through the window in the door to the room and looking and listening for signs of breathing. However it was not routinely part of such observations to check whether the patient had moved or appeared to have remained immobile for an extended period unless there was a particular concern which there was not in Sebast”

2. 2. failure to check patient immobility during hourly observations

   “Notwithstanding the Jury's conclusion that the procedures at the Norvic Clinic could not have prevented [the deceased]'s death | am nevertheless concerned that a failure to specifically check whether a patient has moved or rather remained immobile for an extended period on hourly observations (thereby indicating that perhaps they may have fallen unconscious) could in the future give rise to a preventable death and therefore there is a risk of future deaths occurring and that therefore a review may need”

No published response was found on judiciary.uk.