“That following admission to Southgate Ward Henry Curtis-Williams was seen by a number of…”

The coroner’s concerns

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— (1) That following admission to Southgate Ward Henry Curtis-Williams was seen by a number of different staff members. It became evident that there was a culture of not recording contemporaneous notes. This was very obvious with reference to recording presence or absence of suicidal ideation. (2) There was an acceptance that patients could be discharged by very junior doctors without prior reference to Consultant or Senior colleagues even though Henry had been admitted after being assessed by 2 Section 12 approved doctors and an Approved Mental Health Professional who felt he needed a prolonged inpatient stay. (3) Communication between staff members was very informal with no record kept of important messages relayed. For example, the member of staff who held a one to one meeting with Henry was not present at the ward round where Henry’s case was discussed but said she had verbally passed a message to the ward round nurse. This was normal practice on this ward. There was no record of the message, or of it being passed or that it was considered at the ward round.

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, 2018-0397

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