Stephanie Daniels

the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. _ _ Internal NHS SUL Investigation_ v Independent Investigation am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires prompt; thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken: This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin) In this case there were significant errors and omissions in the SUI investigation: Important witnesses were not interviewed. The in finding the deceased a bed was not a central issue and no specific findings were made about it: The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as They During delay other steps in compliance with the Trusts Rapid Tranquilisation Policy: It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented_ Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that significant failures in the investigative process have occurred: The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March: This is not the first time that the Trust SUI investigations have been found wanting and have experience of other Trusts' investigations also significantly flawed: In conclusion in this sort of case am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved; flawed SUI investigation reports may continue to be produced: This is a policy decision for the NHS but strongly urge consideration of this_
2. Handover AIl the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but have a concern that simple issues may be overlooked: For new patients being admitted or transferred; there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policiesprotocols but experience has shown that what may be delivered on paper is not done in practice. Consequently am concerned that without appropriate audit and clinicalnursing leadership this may prove to be ineffective.
3. Bed Availability MHSC say that following the death of the deceased, a new policy has been introduced s0 that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As understood the evidence from the CCG in the case this should have occurred in any event However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that are not having the appropriate nursing and clinical input; as well as medication review_ In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be: am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts_ Clerking _In The failure to properly clerk in the patient is a matter of serious concern,_especially as many such patients will have physical [1 very being being they health problems MHSC had clear policies requiring the clerking in of a patient; but these were simply not adhered to_ It is common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment; It seems that despite the existence of appropriate policies, in practice these were not complied with_ Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. repeat what have said earlier. MHSC have produced new or updated policieslprotocols but experience has shown that what be delivered on paper is not being done in practice. Consequently , am concerned that without appropriate audit and clinicalnursing leadership this may prove to be ineffective_ Supervision of_Junior Medical Staff am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff: Two junior doctors were asked t0 attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication It is appreciated that they are with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen: They did not notice that the patient had not been clerked in: Medication was being prescribed without adequate consideration of the relevant clinical did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved:
6. Prescribing of Medication bY_Junior Medical Staff am concerned by the circumstances in this case where medication came to be prescribed: There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here: Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. simply prescribed the medication. had no recollection of reviewing the deceased's records but understood that was essential when considering prescribing any medication, and in particular PRN tranquilisation: In this case , the patient was already taking a number of drugs which had sedative effects Two further medications were introduced that have similar properties and that also could potentially affect heart function very being may busy history. They They They rapid

Mechanism by which the Consultant in charge of the patient would learn of thepatient's admission It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken: It would seem that there could be a number of simple solutions for this problem.
8. Pertorming and recording observations on other patients was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during course of the inquest and was brought to the attention of MHSC so that could carry out their own investigations_