“Knowledge of the dangers of mental health patient settings in detained There was evidence…”

The coroner’s concerns

1) Knowledge of the dangers of mental health patient settings in detained There was evidence of steps having been taken by the ELFT at a local level to remedy the apparent lack of knowledge amongst its staff regarding the dangers of ’ and after Mr Smith’s death, including its own substance misuse training and inviting local substance misuse charities back onto its wards to work with its patients and staff as Covid restrictions lift. Bedfordshire and Luton Coroner Service There was, however, various evidence which suggested a lack of knowledge from ELFT staff around and it’s potentially fatal effects, including that several witnesses: (i) Did not know what ‘ ’ or could look like; (ii) Were unaware of how of a person under the influence of ‘ might present; and (iii) Had received no training on the dangers of ‘ ’ or ’ or There was some evidence that this might be a wider issue of concern, both locally and nationally, than only with ELFT staff. In the event that is correct, this report is directed to NHS England and NHS Improvement. 2) The system for assessing risks associated with s.17 leave I was told that, when a staff member is escorting a service user out of the ward, there is an expectation for that staff member to be aware of the location, general mental state and wellbeing of the service user; and that a ‘mental state assessment’ should be carried out on the ward prior to leave taking place, as a further safeguard once s.17 leave had been granted. However, the evidence of the healthcare assistant who took Mr Smith out on leave, on the occasion (29 December 2020) that the jury concluded it was possible that he was able to buy the the misuse of which caused his death, was that: (i) He would not necessarily read a patient’s RiO (electronic continuous) notes before taking a patient out on leave; (ii) He had not read Mr Smith’s care plan before taking him on leave; (iii) There had been no handover from other staff to him of Mr Smith’s presentation on 28 December 2020 presentation (when he was suspected of being ‘under the influence’ of a substance); and (iv) Although he had read the form authorising Mr Smith’s leave (i.e., the s.17 form), that form – a statutory document – does not contain information about particular risks posed to a patient by or when out on s.17 leave. As a result of the above, this particular healthcare assistant was unaware that: (i) On 28 December 2020 Mr Smith had been suspected of being under the influence of drugs; (ii) Mr Smith’s care plan of 20 December 2020 set out as a ‘risk issue’ the fact that “Thomas has a history of using illicit substances”; and (iii) The care plan set out as an ‘intervention’ for Mr Smith: “Nursing staff to do random urine drug screening and breathalysing upon return to the ward.” Bedfordshire and Luton Coroner Service The healthcare assistant therefore appears to have been in a position of escorting a patient on leave without knowledge of a patient’s very recent potential drug-related presentation, or of a specified intervention aimed at reducing the risk posed to that patient by drugs as set out in his care plan. There was, however, no suggestion in the evidence of any witness during Mr Smith’s inquest that the situation in which the escorting healthcare assistant found himself represented a failure to follow policy or expected procedure. In the event that this is correct there appears to be a wider issue – and this Report is therefore directed to NHS England and NHS Improvement.

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, 2022-0225

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