“Evidence was heard regarding the appropriate level of observation by emergency department…”
Dated 5 Feb 2024, from the coroner for North London. Sent to 1 organisation or person.
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 publishedReplies were due by 1 Apr 2024.
Organisations 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 dated5 Feb 2024
- Deadline1 Apr 2024
- Published on judiciary.uk14 Feb 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Hertfordshire Teaching Hospitals NHS TrustNamed in the report as “West Hertfordshire Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in February 2024. |
The coroner’s concerns
a. Evidence was heard regarding the appropriate level of observation by emergency department staff of mental health patients waiting in the emergency department (operated by WHTHNT) to be seen by the mental health liaison team (operated by HYUNFT). There was confusion amongst the WHTHNT witnesses as to the appropriate level of observation. This was contributed to by a lack of clarity in WHTNHT’s (a) Standing operating procedure entitles: management of mental health patients in the emergency department (ED) at Watford General Hospitals (WGH) standing operating procedure (SOP), Issue date August 2021, when compared with (b) WHTNHT’s emergency department adult mental health proforma Version 3 Undated (EDP). b. The SOP states in a section titles 5. Procedure ( on page 4 of 16 Patients at moderate or high risk of self-harm or of leaving before assessment and treatment should be observed closely whilst in the ED. There should be continuous observations and this should be documented in the mental health presentation engagement record. c. Whereas the EDP states at page 7 under the heading: summary of levels of risk and suggested action the following Low: no special observation required Medium: consider 15 minute special observations d. Emphasis has been added above to paragraph (b) and (c) in bold text e. My concern is that the inconsistency between these two documents creates a risk that mental health patients at medium risk of self-harm awaiting assessment for their mental health condition in the emergency department may not be subjected to an appropriate level of observation
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, 2024-0060
- 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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