“6 (1) There appeared to be some inconsistency as to approach to be taken amongst the…”

The coroner’s concerns

– 6 (1) There appeared to be some inconsistency as to approach to be taken amongst the Nursing staff/Health Care Assistants as to when entries should be made in the FACE records following interaction with a patient. It is considered that some guidance/training on this issue would be of benefit to promote greater consistency (2) Erroneously completed NEWS charts – it transpired that Nursing Staff/HCA’s were using the frequency of observation box, to record the time observations were carried out. This may require guidance/training to remind staff completing the NEWS charts of the importance of ensuring the appropriate boxes are completed. (3) Missed Observations – It transpired that NEWS observations ought to have been undertaken at around 7.30am on 8.2.17. There was no record that they had. Whilst there appeared to be systems in place to prompt Nurses/HCA’s to undertake the observations on time – enhanced observations recorded on a white board & the NEWS charts of those patients receiving enhanced observations being separated on the Nursing station, these did not achieve the desired outcome here. It is suggested that more robust ( possibly linked to FACE) procedures should be considered to ensure the observations are performed on time (4) ECG Requests – plan on 8.2.17 was for an ECG to be undertaken. There was no evidence that it had, or had been requested – not documented. The system in place for requesting ECG’s – routine or otherwise appeared somewhat ad hoc and it is suggested that a more robust system for documenting & requesting ECG’s should be considered & implemented. (5) It was considered that some of the detail provided by Nurses/HCA’s when completing the 15 minute observations chart was inadequate. In particular entries such as “bed”. It was accepted that such information was inadequate & a brief addendum adding the condition of the patient was desirable – i.e. recording not simply where a patient was located at the time, but also their state – calm, agitated, sleeping, etc. It was felt that guidance/training on the appropriate completion of these observation charts was indicated, so that patterns of physical & mental health symptoms could be assessed. (6) Consideration should be given to the creation & use of a policy within the Trust for managing opiate dependant patients in the acute admission setting. Whilst the absence of such a policy is unlikely to have altered the outcome here, it was agreed by the Head of Mental Health Nursing that such a policy would be worthy of consideration, to assist clinicians & nurses faced with treating such patients. Such policies are in place in the Aneurin Bevan UHB & C & V UHB, as well as several HB’s in England

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, 2019-0310

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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