“The Trust does not providê nursing cover during weekends and holiday periods of staff…”

The coroner’s concerns

- 1. The Trust does not providê nursing cover during weekends and holiday periods of staff with relevant learning disability training. 2. The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various staqes of.Chloe's treatment. The extent 2 of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located. 3.' The regularity of Chloe'J clinical observations fell well below the expected level. The lapses included a period of over 10 hours in which no observations were . undertaken. 4. Chloe unden¡vent an enema on 8th May 2019 without informed consent being taken. The court found that Chloe was unconscious, before, during, and after the procedure, it is possible this procedure contributed to her death. 5. Nursing staff were incapable of explaining to the court the appropriate criteria that would have to exist before commencing CPR on an unresponsive patient. 6. Governance processes at the Trust failed to identify that Chloe's death constituted a patient safety incident until months after her death. A mortality review authored by the Associate Medical Director on 17th May 2019 assessed Chloe's care as good or excellent. 7 . A Serious lncident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe's treatment. Management failings at the Trust meant that Chloe's death was not reported to a Coroner until August2023, by which time Chloe's body had been cremated denying the court an opportunity to gather relevant evidence through autopsy.

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, 2024-0578

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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