Source · Prevention of Future Deaths
Anthony McManus
Ref: 2016-0388
Date: 31 Oct 2016
Coroner: Thomas Osborne
Area: Milton Keynes
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryConcerns were raised regarding the system of observations, particularly at night, with staff conducting hourly checks at the same time each hour rather than randomly, and some observation charts being completed retrospectively without the checks being performed.
Date
31 Oct 2016
56-day deadline
26 Dec 2016
stated in the report
Responses identified
0 of 1
Coroner's concerns
Concerns were raised regarding the system of observations, particularly at night, with staff conducting hourly checks at the same time each hour rather than randomly, and some observation charts being completed retrospectively without the checks being performed.
View full coroner's concerns
(1) The system of observations carried out within the unit, particularly at night is in need of reform.
(2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly.
(3) Some observations were not carried out and the observation chart completed at the end of the shift.
(4) A robust system of observations should be considered.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636
(2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly.
(3) Some observations were not carried out and the observation chart completed at the end of the shift.
(4) A robust system of observations should be considered.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636
Report sections
Investigation and inquest
On 08/12/2015 I commenced an investigation into the death of Anthony Thomas McManus, 48. The investigation concluded at the end of the inquest on 7th October 2016. The conclusion of the inquest was a detailed narrative conclusion. See attached.
Circumstances of the death
The deceased suffered from a personality disorder and learning difficulties, he was detained under Section 37 of the Mental Health Act. He had been a resident at Chadwick Lodge for a number of years. He was on a standard regime, hourly checks. On 08/12/2015 he was checked at 0200 and not visible. He was then checked again at 0300 and was still not visible so staff entered his room and found him hanging from the back of the bathroom door using a draw string bag. His death was confirmed at 0338.
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Report details
- Reference
- 2016-0388
- Date of report
- 31 October 2016
- Coroner
- Thomas Osborne
- Coroner area
- Milton Keynes
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: 26 Dec 2016 (stated in the report).
Sent to
- Priory Group