Source · Prevention of Future Deaths
Emily Inglis
Ref: 2019-0177
Date: 30 May 2019
Coroner: Mark Layton
Area: Camarthenshire and Pembrokeshire
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted the absence of an overarching risk management plan for the patient's care and treatment. Deficiencies were also identified in record-keeping for risk management strategies and handover records.
Date
30 May 2019
56-day deadline
27 Sep 2019 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner noted the absence of an overarching risk management plan for the patient's care and treatment. Deficiencies were also identified in record-keeping for risk management strategies and handover records.
View full coroner's concerns
(1) The inquest identified that there should have been an overarching risk management plan in place to assist medical professionals and staff in treating and caring for Emily.
(2) The inquest further identified that there were deficiencies in record-keeping, both in terms of ensuring that risk management strategies remained up-to-date and in preserving handover records.
(2) The inquest further identified that there were deficiencies in record-keeping, both in terms of ensuring that risk management strategies remained up-to-date and in preserving handover records.
Report sections
Investigation and inquest
On 22 April 2016, Emily Katherine Inglis was found deceased in her bedroom on the Bryngofal Ward at Prince Philip Hospital, Llanelli, with a plastic bag over her head. At the time of her death she was detained under the provisions of the Mental Health Act. A post-mortem examination report provided a cause of death as plastic bag asphyxia.
On 27th April 2016 I commenced an investigation into the death of Emily Katherine Inglis The investigation concluded at the end of the inquest on 15th April 2019. The conclusion reached by the jury was one of misadventure.
On 27th April 2016 I commenced an investigation into the death of Emily Katherine Inglis The investigation concluded at the end of the inquest on 15th April 2019. The conclusion reached by the jury was one of misadventure.
Circumstances of the death
(1) Emily Katherine Inglis was born on 9 June 1989 and was 26 years of age at the time of her death. She had a history of mental health illness and at the time of her final admission to hospital in December 2015 suffered from a borderline personality disorder. (2) The inquest considered, inter alia, the risk assessments undertaken, the record-keeping and the suitability of an acute psychiatric inpatient unit to treat patients with borderline personality disorder.
Copies sent to
Chief Executive ,Hywel Dda Health Board, Glangwili General Hospital, Dolgwili Road, Carmarthen, Carmarthenshire, SA31 2AF
Similar PFD reports
Report details
- Reference
- 2019-0177
- Date of report
- 30 May 2019
- Coroner
- Mark Layton
- Coroner area
- Camarthenshire and Pembrokeshire
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: 27 Sep 2019 (estimated from the Judiciary.uk publication date).
Sent to
- Glangwili General Hospital
- Hywel Dda University Health Board