Eleanor Brabant

The MATTERS OF CONCERNS are as follows: 5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable patients. 5.2 Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as Eleanor Brabant and their responsibility to report those crimes to the police, whether or not the patient consented. 5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4)

of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. 5.4 It is Trust policy for the families of patients to be involved in care planning, but where the patient has withdrawn consent for information to be shared with their family, witnesses were unclear as to how this should be implemented, and further training appears to be necessary.