“The lack of appropriate contemporaneous clinical record keeping by the nurse in charge as…”

The coroner’s concerns

1. The lack of appropriate contemporaneous clinical record keeping by the nurse in charge as well as other nurses. 5 2. The lack of appropriate contemporaneous clinical record keeping by the Support Workers. 3. Patient observations were not being completed as directed and accurate records were not being kept. 4. There was inadequate communication between the Nurse in Charge and Support Workers about important clinical information relating to self-harm as well as completion of observations and the records. 5. That patients could obtain ligatures and other objects that could be used for selfharm/suicide and/or used against other patients and staff members. 6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator. 7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process. 8. The need for appropriate clinical supervision of nurses and support workers. 9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures. 10. The opportunities missed by the Safety Matters Ltd Serious Incident Investigation report process to obtain other relevant information and/or make additional enquiries which could affect the overall findings and recommendations for learning, improving practice and procedure as well as patient safety. This will also help improve other investigations that the authors of the report may do in the future.

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, 2022-0202

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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