Source · Prevention of Future Deaths
Anthony Fitzpatrick
Ref: 2021-0411
Date: 7 Dec 2021
Coroner: Jason Wells
Area: Manchester South
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryHealthcare professionals used inconsistent and subjective criteria for risk assessment, leading to variable and poorly understood risk grades. The coroner also noted a lack of adherence to online training materials and no plan to address these issues.
Date
7 Dec 2021
56-day deadline
1 Feb 2022
stated in the report
Responses identified
0 of 2
Coroner's concerns
Healthcare professionals used inconsistent and subjective criteria for risk assessment, leading to variable and poorly understood risk grades. The coroner also noted a lack of adherence to online training materials and no plan to address these issues.
View full coroner's concerns
(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of , meaning that (a) the grade of risk assigned to AF was inconsistent and/ or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it.
Report sections
Investigation and inquest
On 28 January 2020 an investigation was commenced into the death of ANTHONY JAMES FITZPATRICK (dob 16 May 1987). The investigation concluded at the end of the inquest on 8 November 2021.
The conclusion of the inquest was .
The medical cause of death was:
The conclusion of the inquest was .
The medical cause of death was:
Circumstances of the death
(1) Anthony Fitzpatrick (AF) had a long history of mental health problems and presented at local A&E departments, with , on 3 occasions in the 12 months prior to his death. On the latter two occasions, in November 2019 and January 2020 he was later taken into custody, at Swinton and Cheadle Custody Suites respectively. (2) Following assessment by the Custody Sergeant AF was seen by a Health Care Professional (HCP, employed by Mitie), who recorded the risk of in the electronic custody record, using a drop down menu.
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Report details
- Reference
- 2021-0411
- Date of report
- 7 December 2021
- Coroner
- Jason Wells
- Coroner area
- Manchester South
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Feb 2022 (stated in the report).
Sent to
- Greater Manchester Police
- Mitie