“During the Inquest, evidence was heard that: - 1”

The coroner’s concerns

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During the Inquest, evidence was heard that: - 1. Staff were unaware of the situations where it was appropriate to breach Patient confidentiality and notify family or friends, when concems arose regarding patient safety/welfare. 2. Ward staff needed to have a greater understanding of how to prioritise New admissions and ensure the better flow of patients through the ward 3. Ward staff and ward doctors need to have a greater understanding of each other's roles and responsibilities in relation to managing patient risk and whose responsibilty itis to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision making rationale (documenting any changes in risk and capacity). 4. Doctors and ward staff involved in making decisions about self - discharge should consider the circumstances of admission as well as Current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to Seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. T request that you undertake a review to ensure staff receive the appropriate training on the issues identified above. 6 | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 March 2020. I, the Coroner, may extend the period.

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, 2020-0072

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