Thomas Smith

16 Jul 2022 · Coroner Tom Stoate · Bedfordshire and Luton

The coroner's concerns

1. lack of knowledge of dangers of substance misuse in detained mental health patient settings
“There was evidence of steps having been taken by the ELFT at a local level to remedy the apparent lack of knowledge amongst its staff regarding the dangers of ' and after Mr [name redacted] death, including its own substance misuse training and inviting local substance misuse charities back onto its wards to work with its patients and staff as Covid restrictions lift.”
2. risk assessment failure for s.17 leave
“However, the evidence of the healthcare assistant who took Mr [name redacted] out on leave, on the occasion (29 December 2020) that the jury concluded it was possible that he was able to buy the the misuse of which caused his death, was that: (i) He would not necessarily read a patient's RiO (electronic continuous) notes before taking a patient out on leave; (ii) He had not read Mr [name redacted] care plan before taking him on leave; (iii) There had been no handover from other staff to him of Mr [name redacted] presentation”