“The adequacy of arrangements in place at Farnham Road Hospital to assess and manage…”

The coroner’s concerns

a. The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk. b. Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms. c. Passage of information between staff concerning patients care and treatment. d. The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital. e. Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room. I received further evidence orally and in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns. This evidence included a response from Surrey and Borders Partnership NHS Foundation Trust (SABP). The Trust outlined a number of prospective measures it is either considering the implementation of, or has plans for their implementation. These measures included: 1. The Trust was reviewing its risk assessment policy, including a new risk assessment tool. 2. Training and induction packages have been reviewed and revised for staff, including junior doctors and temporary ward staff. 3. A draft Care Planning Principles Policy has been developed. 4. The 10 Key Steps to Safety handover document used by the Trust has been reviewed and revised. 5. The Observation Competency Checklist has been changed following review. 6. The Trust is implementing the Systems Engineering Initiative for Patient Safety (SEIPS). It was explained to the court that these measures should be seen in the context of wider cultural change management being undertaken by the Trust at Farnham Road Hospital. 4 I have taken account of the measures, many of which are prospective, as outlined by SABP. However, I remain concerned in relation to the matters identified at sub-paragraphs a to d (above). In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Evidence of the cultural change in the delivery of care and treatment of patients, accepted by the Trust as required, was not provided to the court; either in the form of a plan to bring such change about, or evidence that such change has otherwise occurred. The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk, including the prescription of anti-anxiety medication. Passage of information between staff concerning patients care and treatment. The adequacy of arrangements to manage and implement intermittent observation at Farnham Road Hospital.

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, 2024-0104

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