“During the evidence there was some confusion amongst staff as to what was required of…”

The coroner’s concerns

– a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not enteriing a patient’s room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinved that it is clear as to what is required by staff. b) Following the evidence the Jury concluded:(a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health. (b) that the nursing and clinical records were not kept in accordance with the trust health and record policy. (c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher’s short stay. Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case. c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hosptial for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at risk

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, 2020-0284

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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