Source · Prevention of Future Deaths
Thomas Whitfield
Ref: 2017-0126
Date: 20 Apr 2017
Coroner: Andrew Tweddle
Area: County Durham and Darlington
Responses identified: 0 / 1
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Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.
Date
20 Apr 2017
56-day deadline
28 Jul 2017 est.
Responses identified
0 of 1
Coroner's concerns
Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.
View full coroner's concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] The deceased's sister made a statement advising that she had spoken t0 hospital staff alerting them to the risk that she perceived her brother had of suicide: Her stalement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk: Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient: Consultant Psychiatrist evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns: calls now are recorded for monitoring and training purposes and had such calls being s0 monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time There is CCTV in the hospital, which can be viewed after an event to clarify what didlnot happen:. July gave Many
Report sections
Investigation and inquest
On 8lh August 2016 | commenced an investigation into the death of Thomas Whitfield 62 years old: The investigation concluded at the end of the inquest on 19h April 2017. The conclusion of the inquest was Suicide with a cause of death of Ia) Hanging:
Circumstances of the death
The deceased was a voluntary patient at Farnham Ward; Lanchester Road Hospital, Durham, having previously been detained under Section 2 of the Mental Health Act_ On the morning of 281h 2016 there was an incident on the ward which resulted in the deceased being re assessed by his Consultant Psychiatrist: Within one hour, on a routine observation, the deceased was found hanging in the room: He had not been assessed of been at risk of suicide.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. Your RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15ih June 2017. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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Report details
- Reference
- 2017-0126
- Date of report
- 20 April 2017
- Coroner
- Andrew Tweddle
- Coroner area
- County Durham and Darlington
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Jul 2017 (estimated).
Sent to
- Tees, Esk and Wear Valley NHS Trust