“, - (1) In this case there was confusion as to whether on an in-patient transfer there…”

The coroner’s concerns

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, - (1) In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure. As well as clarifying this process with all providers concerned consideration should be given thata élear documerited process is put in place for in-patient transfers so that all those involved understand clearly the situation and the decision made in relation to the - patient. ‘ (2) Consideration should be given to ensuring that all care plans are time specific .-. so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so again expectations are managed and everyone knows exactly what the plan is and when actions will occur. , (3) That the issue of inconsistent terminology when assessing risk is reviewed fo ensure a consistent approach. In this case there were a number of different phrases and grading’s used to determine the deceased's risk. (4) That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media. (5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient out of area. Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement: how best to re-integrate back into the local area/team.

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, 2017-0369

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