Vijaykumar Gadhavi
28 Feb 2022 · Coroner Nadia Persaud · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of action on self-harm incidents
“Datix reports were generated for the multiple self-harming incidents in July and August 2020. There was no evidence at the inquest, that action and learning had been put in place as a result of these incidents.”
2. missing risk alert on patient records
“Despite the multiple risk incidents and foreseeability of future hospital admissions, there was no alert or flag placed on Mr [name redacted] records to alert new staff to the complexities and risk in his presentation.”
3. absence of medication property list
“Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.”
4. insufficient family involvement
“The recommendations by the learning disability nurse were not fully put into practice. In particular, there was insufficient involvement of his family.”
5. breaches of Enhanced Care Policy
“There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Ms [name redacted] was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost.”
This report
“Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.”
Responses
No published response was found on judiciary.uk.