Source · Prevention of Future Deaths
Christopher James Morgan
Ref: 2013-0272
Date: 22 Nov 2013
Coroner: William Morris
Area: Cambridgeshire
Responses identified: 0 / 1
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The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Date
22 Nov 2013
56-day deadline
12 Feb 2014 est.
Responses identified
0 of 1
Coroner's concerns
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
View full coroner's concerns
That before any change in identified level of risk is decided upon, particularly in relation to access to leave, there is communication with all relevant parties concerned including family and carers to elicit their views The Trust should ensure that a clear practice and policy is adopted in relation to the ratio of staff to patient as to staff that should accompany patients on escorted leave from psychiatric wards
Report sections
Investigation and inquest
On 29th November 2012 | commenced an investigation into the death of Christopher James MORGAN aged 39 years_ The investigation concluded at the end of the inquest on Friday 27ih September 2013. The conclusion of the inquest was that Christopher James Morgan died on November 2013 at Ely Railway Station; the cause of his death was multiple injuries recorded a narrative verdict (see below)
Circumstances of the death
Narrative Verdict Christopher Morgan, voluntary patient at Friends Ward, Fulbourn Hospital, Cambridgeshire, took his own life, dying from multiple injuries when he dived in front of a train at or near Ely Railway Station, on 27th November 2012, in circumstances where he had run away from Fulbourn Hospital earlier in the and in circumstances where there was not in place in the hospital a formal risk assessment covering his supervision at the material time_
Action should be taken
27/h day
In my opinion action should be taken to prevent future deaths and believe that your organisation have the power to take such action.
In my opinion action should be taken to prevent future deaths and believe that your organisation have the power to take such action.
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Report details
- Reference
- 2013-0272
- Date of report
- 22 November 2013
- Coroner
- William Morris
- Coroner area
- Cambridgeshire
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: 12 Feb 2014 (estimated).
Sent to
- Cambridgeshire and Peterborough NHS Foundation Trust