Terence Bennett
14 Sept 2018 · Coroner Nicholas Rheinberg · Wiltshire and Swindon
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. neglect in care
“gross failures in respect of the care provided to the deceased by your trust to the extent that the jury found that the deceased's death had been contributed to by neglect”
2. inadequate care plans
“Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information”
3. lack of staff knowledge
“Staff had insufficient knowledge of how to access, interrogate and effectively use computerised medical records”
4. lack of family involvement
“There was a lack of involvement of family members and in particular, the concept of a triangle of care which involved family, the patient and the medical team had largely been ignored”
5. absence of peer review and audit
“There did not appear to be a system of peer review within the mental health teams nor a system of external audit as regards the adequacy of care plans and medical records”
6. use of unqualified staff
“Unqualified staff were relied upon in circumstances where qualified staff should have been assigned”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“(1) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate.”
This report
“1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information.”