Thomas Whitfield
20 Apr 2017 · Coroner Andrew Tweddle · County Durham and Darlington
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of suicide risk monitoring
“The deceased's sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the”
2. absence of recorded concerns in documentation
“There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.”
3. lack of call recording for monitoring
“Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm and suicide and details of conditions for escorted leave following the formulation meeting on 10" August 2015”
This report
“There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.”
Responses
No published response was found on judiciary.uk.