“Insufficiency of note-keeping”

The coroner’s concerns

– i) Insufficiency of note-keeping. ii) The note made by Dr in the RiO records was described by an independent expert, Dr , as extremely brief. I accept that medical notes should not be defensive in nature but there is nothing at all in it to justify the view expressed that Kirsty was safe to 1 Information Classification: CONTROLLED go home. In a context where she has, over a very recent period, attempted to on five occasions, the rationale explaining how it was felt she was safe to go home should, in my view, have been set out. Of perhaps more significance is that there was nothing in the note to assist clinicians with understanding how the future care plan was to be organised. That was in a context where a national lockdown was imminent. Given the unprecedented circumstances, it seems apparent to me that there was all the more reason to provide detail in this regard. The fact it was not set out, it seems to me, implies that there was doubt on the part of Dr about how the plan to continue treating Kirsty was to be organised. My fear is that this simply passed the burden of the management of the risk to . This reached an entirely foreseeable crisis in the early hours of 23 March. Kirsty had deteriorated to the point she was described as very suicidal. was exhausted from his desperate efforts to keep his wife safe. He rang the ward for assistance. There was no one available to help him. was advised to call the emergency services. He rang the police who told him to ring the ambulance service who told him to ring the CMHT in the morning. This should not have happened. A detailed plan with how to manage an acute deterioration could have prevented it. At the time, Doctor was effectively carrying the burden of two consultant psychiatrists in that Dr was away from work. I indicated at inquest that if this was due to under-resourcing of the Trust, I would write to those responsible for funding. I was advised that, in fact, the problem may be due to a scarcity of consultant psychiatrists nationally. I would be grateful if you could please let me know the position. iii) Lack of involvement of family/carer in discharge process The Trust’s own discharge policy states: 3. Principles The decision to discharge someone from hospital must be in keeping with the Care Programme Approach (CPA), (DH 1991, 2008) and governed by the following principles: The patient, carer and / or advocate, must be actively involved in all aspects of the discharge plan, where practicable. Arrangements for discharge should be negotiated with everyone likely to be concerned with the service user’s aftercare. was Kirsty’s carer. He had not been ‘actively involved in all aspects of the discharge plan.’ He had a phone call to come and collect her and on arriving at the hospital he found her bag to be packed. He did not feel as though he was given any choice. I acknowledged at inquest that there were extenuating circumstances in that Kirsty's discharge coincided with the first national lockdown during the COVID pandemic. Nevertheless, I think it is appropriate to bring to your attention whether there is a need to remind clinicians to involve families and carers in a meaningful way during the discharge 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, 2021-0343

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