“The Trust’s current policy for level two observations requires staff to observe a patient…”
Dated 10 Apr 2024, from the coroner for Somerset. 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 5 Jun 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 dated10 Apr 2024
- Deadline5 Jun 2024
- Published on judiciary.uk29 Apr 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Somerset NHS Foundation TrustNamed in the report as “Somerset Partnership NHS Foundation Trust” | Response publishedPublished on judiciary.uk in April 2024. |
The coroner’s concerns
– (1) The Trust’s current policy for level two observations requires staff to observe a patient not less than five times an hour at random intervals which shall not be more than 15 minutes apart. A possible training issue was revealed during the inquest. Some members of staff who gave evidence at the hearing and in particular one senior member of staff did not appear to have a clear understanding of the policy and there was concern that agency staff might not receive adequate training (2) In a ward where self-harm including use of a ligature was not uncommon there was concern that members of staff and in particular those involved in carrying out observations on patients were not routinely supplied with ligature cutters. 1
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, 2024-0191
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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