“(brief summary of matters of concern) CORONER’S CONCERNS During the course of the inquest…”

The coroner’s concerns

(brief summary of matters of concern) CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Using a monitor screen for Level 3 constant “within eyesight” enhanced observations. The jury found in this case that the deceased could not be seen at all times whist in the de-escalation area, because male healthcare staff moved from observing the female patient from their position in the doorway of the de-escalation room, to view via the monitor in the corridor, when the patient moved into the bathroom, to increase her privacy. Although the Observation policy has been updated since this death in July 2020, by the time of the inquest, the use of the monitor for performing L3 observations was not specifically addressed or prohibited. Although the head of nursing was clear that this should no longer be happening in practice, the current Matron of Ruby ward gave evidence that this was still happening, and although it was now being ‘discouraged’, it was not prohibited. 2. Searching bedrooms on Ruby ward for prohibited items The evidence in this case demonstrated that the deceased had prohibited items in her bedroom on Ruby Ward, including a The search of the patient environment in July 2020 was not effective in identifying and removing items which could be used for self-harm by a detained patient under the Mental Health Act, who was at risk of self harm. The evidence heard at the time of the inquest in February 2022 was that the bedroom searching process does not always include looking into or underneath a patient’s property in their room for concealed items, although some changes to the method and recording of searches are intended. A previous Report to Prevent Future Deaths to the Trust dated April 2019 also identified that the search process on Ruby ward was not effective.

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, 2022-0061

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