Stephanie Cave
16 Nov 2017 · Coroner Philip Spinney · South Wales Central
The coroner's concerns
1. inconsistent approach to enhanced observations
“The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep.”
2. lack of training and written guidelines
“The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms.”
3. missing precise observation times
“The evidence also revealed that precise times of such observations were not routinely being recorded.”