Thomas Jackson

1. 1. poor record keeping

   “During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed.”

2. 2. inadequate multidisciplinary team meetings

   “It is apparent that patients do benefit from regular 'ward rounds' or 'multi- disciplinary team meetings' (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly”

3. 3. lack of awareness of Clozapine significance

   “However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration.”

4. 4. lack of patient education materials about smoking risks with Clozapine

   “| would not wish for patients or their families to be overloaded with paperwork but | wonder if there could be a simple leaflet available to patients and family members covering standard information about treatment generally but including matters such as the dangers of patients smoking whilst they are receiving Clozapine.”

5. 5. lone-working policy gaps

   “| wonder if there needs to be a review of any lone-working policy or procedure with particular reference as to when to enter patients' rooms.”

6. 6. inaccurate Serious Incident Review process

   “the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process.”

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