Winston Harris
3 Aug 2016 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. risk of absconding
“The care plan for Mr [name redacted] did not deal with his risk of absconding. As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour.”
2. lack of written DOLS documentation
“When Mr [name redacted] was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk.”
3. lack of emergency DOLS consideration
“At no time did staff consider if Mr [name redacted] should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS.”
4. delayed DOLS processing
“The application for DOLS order was not processed before Mr [name redacted] death. | heard evidence that it often takes many months to process a DOLS application. Given these are extremely vulnerable people applications should be processed more quickly.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate, seeking further order.”
This report
“The application for DOLS order was not processed before Mr [name redacted] death.”
Responses
2016-0280-Response-by-Birmingham-City-Council.pdf ↗· Birmingham City Council
2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust.pdf ↗· Sandwell and West Birmingham Hospitals NHS Trust