“Critical suicide risk information was not recorded at all or not recorded in a timely…”

The coroner’s concerns

– 1. Critical suicide risk information was not recorded at all or not recorded in a timely manner. On 10/12/23, the experienced nurse did not record at all in the ‘suicide’ box on the ‘level 1 – risk screening’ the first report of suicidal ideation via road traffic collision. She described this omission as an error and the likely explanation was that she was the only nurse working on a very busy shift. On 11/12/23, the experienced nurse did not in a timely manner record in the ‘suicide’ box on the ‘level 1 – risk screening’ the second report of suicidal ideation via road traffic collision received by 11am. She said the likely explanation for not updating the ‘suicide’ box until 8:51pm (and after the nurse-in-charge made his transport risk formulation) was that she was the only nurse working on a very busy shift. The experienced Nurse-in-Charge did not record at all his transport risk formulation saying that was not his usual practice. The Patient Safety Manager said long standing trust policy required clinicians to record key information as soon as possible. I am not persuaded this long standing policy is sufficient by itself to remove the risk in the future of critical suicide risk information not being recorded at all or in a timely manner given three experienced nurses within 24 hours failed to follow the policy. 5 2. Post-death trust learning led to new guidance for when an informal patient requests family, carer, or friend transport them from PDU. For ease of reference it states: “Where appropriate, it is reasonable for the option of an informal patient to be transported by family/carer/friends. In all such cases, decision needs to be based on the risk/benefit ratio and this also needs to be clearly discussed with the person transporting to make sure there is understanding and agreement. This needs to be clearly documented within the patient’s notes. If there is any concern or disagreement expressed by the person, family/carer/friends, then alternative arrangements need to be made by us.” I am not persuaded this is sufficient to remove the risk of an inadequate risk assessment in the future. By way of contrast, trust guidance C52 ‘Mental Health Act Transport of Patients’ - which applies when a patient has been assessed under the Act and ambulance service transport is to be used - at paragraph 12 includes 15 specific questions that the risk assessor should ask as part of the transport risk formulation, including: How far does the patient have to travel? What is the patients age and gender? What is their current state of mind? Is there a risk to the driver/accompanying individuals? The updated guidance cited above is absent any equivalent specific questions or assistance on when it is or is not appropriate. For example, in Kieran’s case clinicians were aware his sex, age, and background of relationship breakdown statistically recognised him as being at a higher risk of suicide, PDU is only intended for a brief stay whereas Kieran was there for nearly 48 hours and his state of mind was not assessed in the hours before the risk formulation (even thought it was known to fluctuate), the journey if considered would have been noted to take him away from local roads onto a high speed motorway, and his wife/the driver was known to be a trigger for his low mood. Further, there was no consideration of what his wife had to be told to ensure she was safe, providing genuine informed consent given the interplay of patient confidentially. In Kieran’s case the transport risk formulation did not consider whether his risk of suicide included road OFFICIAL traffic collision vs an unrelated mechanism. My concern is the above cited guidance in simply stating the decision should be based on ‘appropriateness’ and ‘the risk/benefit ratio’ does not sufficiently prompt clinicians to consider the full range of key issues and is inconsistent with the more expansive guidance in C52 for when an ambulance is to be used. For completeness, (1) there was discussion during the inquest about why there cannot be a blanket ban on informal patients with recent suicidal ideation via road traffic collision being transported by family etc given they represent a very small cohort of patients. If no such ban is considered appropriate, in my view, the need for more expansive and specific guidance for clinicians equivalent to C52 is increased, and (2) there was discussion at the inquest of a transport risk formulation based on a points system with a written draft suggestion from the Family’s counsel; I attach a copy which may be of assistance for the trust when deciding what if any action to take.

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, 2024-0422

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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