“A failure to adequately assess risk of harm - Poor record keeping and a failure to read…”

The coroner’s concerns

1. A failure to adequately assess risk of harm - Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team ("MDT") ward round on 6th April 2021 . The MDT arrived at a conclusion that Mr Charles' risk of self-harm was "no risk". A psychologist's assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion. 2. A decision to reduce observation frequency made by the MDT on 6/4/21 was not supported by the Trust Policy guidance which indicated that enhanced observations were appropriate. 3. A failure to ensure that a treatment plan was followed - observations between 16.00 and 17.00 on the day of Mr Charles' death were suspended by the ward shift co-ordinator. The decision meant all patients subject to general observation on the ward were ignored. 4. Failures to respond to an emergency adequately - The Trust described the emergency response as chaotic . Staff agreed that they "panicked" and did not follow policy, specific issues include; a . A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles' door, instead the door was forced open causing a risk of harm to Mr Charles. C. A ligature cutter could not be used promptly as it was secured in a box with a combination lock - staff did not know the combination, d . Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. 5. The credibility of evidence provided by Trust staff. a. Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful. b. Observation records appeared to have been created utilising a "cut and 2 paste" function. Records often inaccurately recorded the prescribed frequency of observation. d . Factually inaccurate entries were made in the record following Mr Charles' death. On 11 th April 2021 an entry stated that Mr Charles was, "Awake in his bedroom sitting on his bede (sic)" at 07.21 . On 12th April two entries made at 9.48 and 11 .40 recorded that Mr Charles' was alive and well. Senior Trust witnesses characterised these entries as dishonest. C. 6. Governance process failings. a . A datix incident report created on the evening of 10th April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not. b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action. C. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021 . d. The Trust SI report presented to the inquest failed to address the poor risk assessment or inadequate datix & 72 hr reports.

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, 2023-0143

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