“System by which observations and documentation are audited lacks rigour and is ineffective”
Dated 1 Nov 2022, from the coroner for Manchester North. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated1 Nov 2022
- Deadline27 Dec 2022
- Published on judiciary.uk18 Oct 2023
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Greater Manchester Mental Health NHS Foundation Trust | Response publishedPublished on judiciary.uk in October 2023. |
| NHS England | Response publishedPublished on judiciary.uk in October 2023. |
The coroner’s concerns
1. System by which observations and documentation are audited lacks rigour and is ineffective. 2. At the time of the CCTV review and investigation following Rowan’s death there was a missed opportunity for management to understand the gravity and nature of the situation. There was no higher level investigation, so for example: a) Whether the staff who failed to complete observations/falsify records did so when working a particular shift ie night shift b) Whether the staff who failed to complete observations/falsify records did so when working weekends rather than during the week c) Whether there was any correlation between missed observations / falsifying of records and shifts when there was no deputy or ward manager on duty. 3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3 rd October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit.
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, 2023-0365
- 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
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