“During the hearing it was noted that on a number of occasions record keeping was poor”

The coroner’s concerns

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(1) During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed. | wonder if the Trust can take any action to improve this. (2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi- disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate. (3) It is clear that Clozapine is a beneficial drug for many patients and that a large number of patients in the care of the Trust do receive this drug. However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration. (4) | would not wish for patients or their families to be overloaded with paperwork but | wonder if there could be a simple leaflet available to patients and family members covering standard information about treatment generally but including matters such as the dangers of patients smoking whilst they are receiving Clozapine. (5) | wonder if there needs to be a review of any lone-working policy or procedure with particular reference as to when to enter patients’ rooms. (6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. | understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process.

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, 2018-0352

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