“that do not appear to have been addressed and the evidence also revealed other matters…”

The coroner’s concerns

that do not appear to have been addressed and the evidence also revealed other matters that have not been identified in the Trust’s improvement plan. The MATTERS OF CONCERN are as follows: 1) Record Keeping / Professional Standards There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to makes notes on the records system, without making it clear who the entry was actually made by. In this case there were two entries that appeared to have been made by a support worker, that were actually made by a nurse. Such misleading and inaccurate record keeping risks significant confusion in the provision of care and potentially creates significant risk in relation to the continuity of care. 2) Lack of Professional Curiosity / Therapeutic Engagement – Audits This was a matter picked up during the Trust’s own investigation. The Trust’s action plan includes audits to monitor compliance with certain aspects of Trust policy etc. However, the Topaz Ward manager gave evidence that there had been issues with audits in the past, which had been escalated (prior to Ms Crane’s death) but no response received. I was not reassured that further audits would be sufficient to address the concerns already identified. In addition to the above, numerous members of staff from Topaz Ward gave evidence during the inquest and it appeared that many of them struggled with the concept of ‘therapeutic engagement’. Some maintained that Ms Crane had received a sufficient level of therapeutic engagement from Ward staff, contrary to the findings of the Trust’s own investigation and the subsequent findings of the jury. This suggests a potentially widespread lack of understanding, and underlying knowledge of ‘therapeutic engagement’ and its importance in mental health care. 3) Step down / discharge from PICU to acute ward There was evidence that the Trust’s systems were unable to accommodate the needs of Ms Crane in ensuring that her transition from an intensive care to an acute setting was as safe as possible for her. Numerous risks and needs were identified for the step down / discharge process, but most of these (which significantly impacted Ms Crane’s risk to self) were not facilitated. 4) Therapeutic Engagement / Professional Curiosity – Generally The jury heard evidence from numerous members of Topaz Ward staff who were taken through the care records, that Ms Crane had become withdrawn from around 12 September 2024 onwards. Many of the witnesses denied this, despite the evidence to the contrary. The fact of Ms Crane becoming withdrawn had been identified by staff in PICU as a significant risk factor for Ms Crane. While this may not have been picked up by all staff due to record keeping issues (already identified by the Trust), the concern here is that there appears to have been a general inability among staff to recognise when a patient is becoming withdrawn, which raises concern about underlying professional curiosity. 5) Observations on Topaz Ward The Trust’s own internal investigation highlighted issues regarding the review of required observation levels. However, the evidence at inquest, in relation to the observation round at or about 11:30 on 19 September raised a further concern, albeit this did not cause / contribute to Ms Crane’s death in the particular circumstances. The evidence was that the support worker conducting this check did not see any part of Ms Crane, and on trying to open the door noted there was some resistance. As such, the assumption was made that Ms Crane was sat with her back to the door, and the support worker marked Ms Crane as being in her room and moved on to the next room. This raises the concern that observations being undertaken do not always comply with the Trust’s own observation policy and that there may be a staff training / knowledge gap in this regard. 6) Communication and Culture While the Trust’s internal investigation highlighted issues with documentation and record keeping, which is key tool for communication, the evidence revealed a lack of general communication between staff at all levels. Aside from documentation matters, a lack of good communication more generally raises significant patient care risks and could undermine patient safety. The substantive consultant psychiatrist for Topaz Ward said that they would change nothing about the care that was provided. This raises concerns that the senior clinician for the Ward does not accept or appreciate the issues identified by the Trust. 7) Trust Action Plan Some of the matters contained within the Trust’s action plan, which stems from its own internal investigation, remain outstanding and / or are still awaiting Board level approval. As such, there is, to some extent, a lack of reassurance (at present) regarding the actions that will actually be taken to address the risks the Trust itself has already identified.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0317

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0