Source · Prevention of Future Deaths

Daniel Williams

Ref: 2014-0009 Date: 6 Jan 2014 Coroner: Nicola Mundy Area: South Yorkshire (East) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.

Date 6 Jan 2014

56-day deadline 3 Mar 2014 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.

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(1) Quality of staff training, particularly with regard to record keeping and communication.

(2) The emphasis on taking a holistic approach to care and whether there is an imbalance between adopting such an approach and patient safety.

(3) The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital.

(4) The absence of a single reference sheet in the notes summarising key issues, risk factors, significant incidents and concerns readily accessible to all involved in patient care.

Responses

1 respondent

Response

PDF

AI-classified response stance Action Taken

AI-generated response summary

• All Inpatient staff received training packs and completed e-learning on 'Personalised Care Planning 2013 Record keeping and communication' in November. • The Trust developed and distributed guidance for checking searches to address the absence of clear Standard Operating Procedure for room searches, with the policy for searching a person for potential self-harm property updated in February 2014. • A front page outlining current Risk and Electronic Records issues, management plan, significant incidents, and service provider information has been integrated into the Electronic Patient Record (EPR) system.

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Report sections

Investigation and inquest

On 21st June 2013 I commenced an investigation into the death of DANIEL WILLIAMS, AGE 24. The investigation concluded at the end of the inquest on 2ND JANUARY 2014. I concluded that the cause of death was 1a HANGING and returned a NARRATIVE CONCLUSION as follows:

In May 2013 Daniel Williams was admitted to St Catherine’s Hospital following an episode of deliberate self harm by way of insulin overdose. This was on a background of psychiatric problems which developed following a diagnosis of diabetes which had profoundly effected him.

During the course of his admission superficial enquiries by staff and unreliable record keeping compromised the quality and completeness of the clinical information which in turn compromised the effectiveness of the risk assessments. Poor communication exacerbated matters. All these factors served to further increase Mr Williams’ significant risk of self harm.

On 15 June 2013 Daniel Williams died from hanging following self application of a ligature in his room at St Catherine’s Hospital.

Circumstances of the death

Daniel Williams had been diagnosed as suffering from Diabetes as the age of 19. This profoundly affected his mental wellbeing and also had physical implications too. As a consequence he engaged with the psychiatric services and his final admission to hospital was on the 23rd May 2013 following an overdose of insulin. Mr Williams suffered from suicidal thoughts for much of that admission and appeared to be considering alternative methods for ending his life. There were a number of risk assessments and one to one meetings, many of which appeared not to explore in any depth his suicidal thoughts and intent. On the 15th June 2013 Mr Williams hanged himself with a bedsheet by knotting one end and securing it in the door jamb to the en suite bathroom and tying the other end tightly around his neck.

Inquest conclusion

In May 2013 Daniel Williams was admitted to St Catherine’s Hospital following an episode of deliberate self harm by way of insulin overdose. This was on a background of psychiatric problems which developed following a diagnosis of diabetes which had profoundly effected him.

During the course of his admission superficial enquiries by staff and unreliable record keeping compromised the quality and completeness of the clinical information which in turn compromised the effectiveness of the risk assessments. Poor communication exacerbated matters. All these factors served to further increase Mr Williams’ significant risk of self harm.

On 15 June 2013 Daniel Williams died from hanging following self application of a ligature in his room at St Catherine’s Hospital.

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Shared signals

Report details

Reference: 2014-0009
Date of report: 6 January 2014
Coroner: Nicola Mundy
Coroner area: South Yorkshire (East)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Mar 2014 (estimated from the report date).

Sent to

Rotherham, Doncaster and South Humberside NHS Foundation Trust

Part of a series

2 reports

2019-0309 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.