Tracy Wood
11 Apr 2022 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. staffing levels insufficient
“[the deceased] was placed on Yare Ward, an acute ward which was staffed in accordance with "Safer staffing levels”
2. Duty Psychiatric Doctor not attending
“Following [the deceased] on the evening of 1 June 2021 the Duty Psychiatric Doctor was called to attend to see and assess [the deceased], but did not attend”
3. administration of prohibited item
“[the deceased] on 30 March 2021 and a note was placed on her SBAR records in red and bold "Do not give [the deceased]”
4. source of prohibited item unknown
“Following [the deceased] on the evening of 1 June 2021, there was no investigation as to where she obtained the”
5. inaccurate record keeping
“Written records did not specify correct dates and times as to events, for instance the Event Date/Time of the incident on 1 June 2021 at 20:53 hours is recorded in the Clinical Notes as "02 Jun 2021 06:49”