“Level 2 observations were not conducted at the prescribed time intervals and periods of…”

The coroner’s concerns

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— 1. Level 2 observations were not conducted at the prescribed time intervals and periods of up to two hours lapsed between observations that should have been conducted every 15 minutes. When observations were conducted they were not always carried out as per the protocol. Assurances have been given at previous inquests that the performing and recording of these observations would be monitored, audited and staff would be trained regarding the importance of such observations. The same assurances were given at Mr. Hughes’ inquest. It therefore appears that changes have not been made or if they have they are not working. Alternatively, changes may occur in the short-term but they are not being maintained and therefore the monitoring and auditing systems, if implemented, appear not to be working. 2. Fluid balance charts were not properly completed. There was no uniformity as to how or when staff would record fluid intake. Some staff would record fluid if they gave Mr. Hughes a drink, Some would record if they witnessed Mr. Hughes drink it. Therefore, the fluid balance charts were rendered meaningless. 3. Patient bedrooms are not fitted with a call bell system. The staff rely on patients being able to leave their bedroom and seek help or be able to shout loudly enough to be heard. Clearly, a patient who is so unwell that they can do neither would not be able to alert staff that assistance was required. 4. The nursing staff who gave evidence were Registered Mental Health Nurses or Health Care Support Workers. The evidence that they gave suggested they may not appreciate the signs and symptoms of a physical problem / illness. One nurse said that he would not. Although it is understood that discussions have taken place regarding the recruitment of 5 Registered General Nurses to supplement the 2 already in post at the Bradgate Unit and address this concern, it is understood that recruitment has not yet occurred and no date for commencement of recruitment could be given.

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, 2016-0040

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