“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. The ward layout did not lend itself to easy observation of patients. The Court’s expert considered it ‘wholly inadequate’. The jury felt that this contributed more than minimally to Katharine’s death. A number of rooms (including Katharine’s room, 23) were remote from the nursing station and largely out of sight unless visited for a specific purpose. Whilst I am aware that some changes have been made since 2018, I am concerned that the current layout continues to place vulnerable patients, who might take their own lives, at risk. It is appreciated that the Trust might not be in a positon to create a ward which eliminates all of the layout issues. However, mitigation measures might be appropriate if the present facilities are to be used on an ongoing basis in an unmodified form. I am concerned that the limitations presented by the current layout may mean that staffing levels need to be adjusted to allow for greater levels of informal observation, oversight and monitoring. 2. The argument with her husband was a trigger event for Katharine. She was seen briefly by some ward staff between her return to the ward at around 10:25 and 11:00, but left completely unattended between 11:00-12:00. The jury felt that there was a missed opportunity at this time to affect the outcome and that the assessment of the risk that Katharine posed to herself had been inadequate. The evidence indicated that ward staff (seemingly regardless of their level of experience and seniority) who attend a patient in a situation like this are left to determine what (if any) action to take based upon their clinical judgement. In particular, it is left to the individual to decide whether escalation to a senior clinician would be appropriate and whether observations or monitoring (or even simply staying with the patient) should be increased for a period of time. I was told that it would not be unworkable in any scenario such as this (involving knowledge of a trigger event in the case of an impulsive patient with a known history of suicide attempts and self-harm) for there to be a procedure which called for an automatic review by the senior clinician on the ward at the time. However, that is not the current situation. I am concerned that, in the absence of a clear protocol, relatively junior staff (who may not be able to effect an adequate risk assessment) may not be equipped to determine how best to address the short-term 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, 2022-0307

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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