Sharon Langley

1. 1. delayed emergency response

   “Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding [the deceased] unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack”

2. 2. unsecured high-risk doors

   “The Trust was on notice of issues on Chelmer ward with doors to high- risk areas not closing that included the Staff Room and Patient Storeroom”

3. 3. missing self-closure mechanisms

   “Self-closure mechanisms have not been fitted to these doors in a high- risk environment of a secure psychiatric ward even though the risk is known”

4. 4. inadequate incident reporting

   “Chelmer Ward staff did not always report door closure issues either on the ward to the Nurse in Charge or to maintenance”

5. 5. inadequate investigation

   “There is concern about the reliability of the Trust investigation and how the Trust learns lessons”

6. 6. poor record keeping

   “of record keeping was not deemed to be appropriate by senior staff during evidence: a. Significant examples of cut and paste including out-of-date risk information at all grades of ward staff, and omissions in multi-disciplinary decision-making and risk of self-harm with no rationale for the level of observations set for the patient and a plan for how risks should be managed”

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