“There was inconsistence records of engagement with service users”
Dated 17 Jul 2015, from the coroner for Avon. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 11 Sep 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated17 Jul 2015
- Deadline11 Sep 2015
- Published on judiciary.uk17 Jul 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Avon and Wiltshire Mental Health Partnership NHS Trust | Response publishedPublished on judiciary.uk in July 2015. |
| Care Quality Commission | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 11 Sep 2015. A reply may have been sent and not yet published. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) There was inconsistence records of engagement with service users. The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded ina consistent manner with appropriate staff training in application of the policy. (2) There was no one member of staff with overarching responsibility for reviewing any risk assessments. Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified. The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date. (3) The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any eniries in the care record nor would be present at the ward round. The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions .
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, 2015-0283
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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