Source · Prevention of Future Deaths
Darren Linfoot
Ref: 2015-0089
Date: 9 Mar 2015
Coroner: Peter Bedford
Area: Berkshire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted that non-controlled drugs, including opiates, are not audited, posing a risk of potent medication being unaccounted for. There was also a lack of consistent understanding and methods among nursing staff for performing regular patient observations.
Date
9 Mar 2015
56-day deadline
4 May 2015 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted that non-controlled drugs, including opiates, are not audited, posing a risk of potent medication being unaccounted for. There was also a lack of consistent understanding and methods among nursing staff for performing regular patient observations.
View full coroner's concerns
(1) The evidence was that a variety of drugs and medications are dispensed from the hospital’s in-house pharmacy for use of individual patients on the individual wards. Only controlled drugs are audited and their whereabouts monitored. Among others, Opiate drugs are classed as non-controlled and are therefore not audited. There is a real risk that potent medication could go unaccounted for and could end up in the possession of patients.
(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations. It is suggested that a consistent method is identified and appropriate training is provided.
(3) Nursing staff also gave inconsistent evidence about the duties of the radio nurse on the admissions ward. There appeared to be a need for consistency and appropriate training.
(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations. It is suggested that a consistent method is identified and appropriate training is provided.
(3) Nursing staff also gave inconsistent evidence about the duties of the radio nurse on the admissions ward. There appeared to be a need for consistency and appropriate training.
Report sections
Investigation and inquest
On the 4th March 2015 I concluded an Inquest into the death of Darren Linfoot, a thirty-three year old detained patient at Broadmoor Hospital. The Inquest was heard before a Jury.
Circumstances of the death
On the 18th December 2011 Darren Linfoot was declared deceased at Frimley Park Hospital, Surrey. He had been a patient at Broadmoor Hospital since the 17th November 2011 and he was found unresponsive in his room in the hospital by nursing staff. A post mortem examination found a cause of death of Lobar Pneumonia to which Dihydrocodeine Toxicity contributed.
Copies sent to
of Mr LinfootPeter J. Bedford Senior Coroner for Berkshire
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Report details
- Reference
- 2015-0089
- Date of report
- 9 March 2015
- Coroner
- Peter Bedford
- Coroner area
- Berkshire
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: 4 May 2015 (estimated from the report date).
Sent to
- West London Mental Health NHS Trust