“2 1”

The coroner’s concerns

- 2 1. Documentation of key stages in Mr Morton's care was poor or non-existent. Critical decisions on; mental capacity, best interests, the choice of sedation, the amount of drug administered, the method of administration and the timing of administration were not clearly recorded. ln multi-clinician treatment contemporary documentation is essential to preserve patient safety. ln this case the lack of clear documentation meant that some clinicians were unaware that Elvon was sedated, whilst others were ignorant of the fact that he had declined treatment. 2. Witnesses blamed poor documentation on workload, specifically an influx of acute patients into the resuscitation bays. Despite this, no evidence was presented that any attempt was made to mitigate this pressure by, escalating the matter to the site manager, nor did the on-call ED consultant find it necessary to come in to the unit. These actions tend towards a "coping culture" inconsistent with patient safety. 3. The decision to sedate Mr Morton was flawed. The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision. ln the absence of clear and reasoned evidence of decision making, weight must be attached to evidence heard that Elvon's; size, sex and race triggered a heightened response by hospital staff to his agitation, leading to security officers being called. lt was in this febrile atmosphere that the decision to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and intubation, was made. 4. A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remed iate su b-opti mal practice Elvon's relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust's acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed. ln this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings. Additionally, despite preparing for an inquest, neither the Trust's legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.

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, 2024-0258

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