Mark Bartholomew

Notwithstanding the Trust's policy entitled '2999 Procedure' the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly: - The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available_for_the_Inguest Jury July

Originally; a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased's death to the family. By reason of a lack of communication; the family were notified following an attendance by uniformed officers whereupon the deceased's Mother telephoned the Trust: Liqature Cutters The Consultant Forensic Pathologist confirmed in evidence that time was very much of the essence Specifically he stated 'Tfollowing application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a attached to a hook on the wall in the secure clinic. ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking; the absence had gone unnoticed_ The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later . To the credit of the Trust; the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift. Although alerted to Department of Health guidance from 2007 , can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in pouch by Custody Sergeants within the Custody Office of designated Police Stations_ The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement; the ligature would have been released within a matter of seconds rather than minutes_ The Trust has documented Observation Policy: Whilst the Policy requires records to be contemporaneously recorded, it does not specify how this is to be achieved_ The actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed and in its present format would not withstand a rigorous audit.