Response
Action Planned
AI-generated response summary
• The organisation stated it would review and update its Levels of Observation Policy for ratification and implementation. • It committed to reviewing and amending enhanced observation recording documentation, introducing a trial, and then implementing the evaluated documentation. • The organisation indicated it would amend documentation forms to include additional guidance and update its training package for staff on conducting and recording observations.
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Ludlow Street Healthcare & Heatherwood Court Hospital Response to Regulation 28: Report To Prevent Future Deaths Issued by Mr Philip C Spinney, HM Area Coroner, 6 December 2017
Action required by Coroner Action Rationale Person responsible for action Date for completion Consideration should be given to reviewing the process of conducting and recording enhanced observations of patients detained under the mental Health Act and at risk of self-harm or suicide Review and update Levels of Observation Policy for ratification by the Policy Committee
Circulate and implement new policy
Review current enhanced observation recording documentation
Introduce amended recording documentation for 2 week trial commencing 22 January, 2018 with provision for coaching of staff, monitoring and evaluation
Introduce evaluated amended documentation
To consider current policy in relation to the matters of concern raised by the Coroner e.g. by clearly outlining training provided to staff , Registered Manager, with Operational and Board involvement
Policy Committee
, Registered Manager, with Operational involvement
, Registered Manager, , Clinical Lead Manager with Unit Manager support
with administrative support 31 January 2018
12 February 2018
26 January 2018
4 February 2018
5 February 2018
Consideration should be given to introducing training and written guidance on how to conduct and record enhanced observations of patients detained under the mental health Act and at risk of self-harm or suicide Amend documentation form used for recording enhanced observations to include additional guidance on conducting and recording enhanced observations & additional requirement to record actual time that observation is undertaken
Update current training package to include: video that clearly shows the correct way to complete the documentation exemplar copies of completed for the finalised documentation record
To promote more consistent approach by staff in their conducting and recording of enhanced observations and to increase the amount of information recorded
To provide more specific training and guidelines for staff in respect of completing and recording their observations , Registered Manager
, Clinical Lead Manager
19 January 2018
12 February 2018
Action required by Coroner Action Rationale Person responsible for action Date for completion Consideration should be given to reviewing the process of conducting and recording enhanced observations of patients detained under the mental Health Act and at risk of self-harm or suicide Review and update Levels of Observation Policy for ratification by the Policy Committee
Circulate and implement new policy
Review current enhanced observation recording documentation
Introduce amended recording documentation for 2 week trial commencing 22 January, 2018 with provision for coaching of staff, monitoring and evaluation
Introduce evaluated amended documentation
To consider current policy in relation to the matters of concern raised by the Coroner e.g. by clearly outlining training provided to staff , Registered Manager, with Operational and Board involvement
Policy Committee
, Registered Manager, with Operational involvement
, Registered Manager, , Clinical Lead Manager with Unit Manager support
with administrative support 31 January 2018
12 February 2018
26 January 2018
4 February 2018
5 February 2018
Consideration should be given to introducing training and written guidance on how to conduct and record enhanced observations of patients detained under the mental health Act and at risk of self-harm or suicide Amend documentation form used for recording enhanced observations to include additional guidance on conducting and recording enhanced observations & additional requirement to record actual time that observation is undertaken
Update current training package to include: video that clearly shows the correct way to complete the documentation exemplar copies of completed for the finalised documentation record
To promote more consistent approach by staff in their conducting and recording of enhanced observations and to increase the amount of information recorded
To provide more specific training and guidelines for staff in respect of completing and recording their observations , Registered Manager
, Clinical Lead Manager
19 January 2018
12 February 2018