Ruth Whitmore

_ _ [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed frailty, Leg day to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff.

(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient: No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events_ It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough_