"GDPR Says Yes"

Regina was bed-bound following a hip operation, and was receiving double-handed domiciliary care 4 times per day. Her daughter was dissatisfied with the quality of care provided and asked for it to stop. There was no assessment of Regina's ongoing needs or her mental capacity, nor of her daughter's ability to understand and meet them.

Care home staff kept poor quality records of Wendy's condition. As a result her skin condition was not being managed properly, and she died as a result of pressur ulcers. The electronic care management system was not being used effectively, and the care home managers weren't able to monitor risks.

Linda had learning difficulties and a mental health condition. She was under the care of the MH team, but they failed to notice her LD and made no reasonable adjustments. Linda overdosed on her medication, and died as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease

"Matthew’s death was probably the result of systemic failures across multiple agencies including the Prison services.... There was inadequate communication between agencies and a lack of information sharing. This probably led to a failure to identify his deteriorating mental health and increasing suicide risk.

System used to record welfare checks (Excel) was unfit for purpose, as were staff processes for completing and recording these checks.

Staff at Peter's residential home failed to follow his Eating and Drinking plan, as a result of which he choked.

Anna was sectioned as she had suicidal thoughts. She was not observed as she should have been, partly due to staffing pressures, but staff backfilled the observation records to show that obs were being carried out correctly. The Coroner also noted an issue about messages from Anna's mother not being recorded or passed to staff, and about poor handover from day to night shift staff.

Discharge and safety netting The discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers. The information within the discharge report was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals. Review of the medical notes There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state. Failure to update risk assessment There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s presentation had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments. Record Keeping There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records.

Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody. (The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.) The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.

Karmchand was admitted to hospital with acute intestinal obstruction. He was placed on the wrong referral pathway, resulting in severe delay to the surgery he needed. Observations were not carried out properly while he was awaiting surgery. Karmchand was unable to communicate the pain he was feeling to hospital staff. His family raised concerns, as did hospital staff who knew him, "but adequate notice does not appear to have been taken."

Morgan-Rose took her life while sectioned under the MHA. She was 18 with a diagnosis of Autism Spectrum Disorder; her transition from Children's to Adult1 Social Care had been badly managed, with a lack of information transfer between the two serevices and with no consideration of her own anxieties. MHU staff consistently failed to engage with Morgan-Rose, to the point where she felt they didn't have time for her. They failed to monitor her as they were required to, falsifying observation records and relying on the Oxevision automated observation system instead of face-to-face observations. When Oxevision triggered an alarm to say she had been unattended in the bathroom for three minutes, which should have resulted in an immediate welfare check, the system was reset by an unknown person and Morgan-Rose was left in the bathroom for 50 minutes. Staff had also failed to pick up on warning signals in her behaviour which should have led to heightened alertness. Basic record-keeping was extremely poor, as was the oversight and monitoring of records by senior staff.

Rhys was discharged from hospital following spinal surgery. He and his family were not given clear information about post-surgical risks of VTE or how to mitigate them. He was offered medication, but in the absence of any advice about why it was needed, he declined it. The decision-making process around his discharge was found to be deeply flawed.

Repeated failures by ASC to respond to multiple reports of safeguarding concerns and requests for Carer Act assessments

Miles was arrested while driving under the influence of drink and drugs. He had longstanding mental health needs and was experiencing a psychotic episode. The Police appear not to have realised this and didn't carry out any meaningful assessment of his mental health. They didn't pay adequate attention to information provided by his parents, Adult Social Care and the Mental Health Line. Miles was released from custody, and subsequently crashed his car into an HGV while still suffering a psychotic episode.

Sam's mother had taken her own life when he was 15. He was deeply affected by her death and committed suicide in prison shortly after the 7th anniversary of his mum's death. Although prison staff were aware of how his mum's death had affected Sam, there was no record of a trigger date in either NOMIS (the prison service system) or SystmOne (the prison healthcare system).

The current SCR model does not appear to automatically flag drugs such as steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not. In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated.

Information about the frequency of Charlie's observations was not completed until after his death. The Coroner noted two earlier PFD reports about the same MHU which raised the same concern.

1. Awareness of and compliance with St. Andrew’s Healthcare ‘Pressure Ulcer Prevention and Management’ Policy Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from [REDACTED], Consultant Psychiatrist, [REDCATED]and, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi’s waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH ‘Pressure Ulcer Prevention and Management Policy’ was not followed in Mr. Mishabi’s case. At inquest it was identified that [REDACTED] had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows: a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy; b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy; c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy; d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi’s case in accordance with paragraph 5 of the policy. 2. SAH Governance, Quality Assurance and Serious Incident processors a. SAH had not identified the issues with compliance with the policy before the inquest and could offer no explanation for how/why the failures occurred and persisted. b. No serious incident investigation had been carried out by SAH into Mr. Mishabi’s death because it was mistakenly believed that the ulcers developed during the admission to hospital between the 17th March and 2nd April 2023. However, it was acknowledged in a statement from [REDACTED]of the 14th September 2023 that there were records showing ulcers were present from the 15th March 2023. c. [REDACTED] SAH Deputy Medical Director, gave evidence that the failures to comply with the policy ought to have been identified by review of the physical health dashboard in monthly ward governance huddles and the monthly divisional Integrated Quality and Performance meeting (IQPR). As there had been no investigation into what went wrong she could not explain why these systems did not work.

"The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk. "The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place."

1. There was a limited risk assessment and risk management plan documented for Gerard on ward B2 now Beech ward 2. There was an inadequate door board system for monitoring the return of patients after unescorted leave on ward B2. The same arrangements remain currently, despite the ward move to Beech ward on new premises 3. There was extremely limited family and carer involvement in Gerard’s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward 4. There was limited awareness of the ligature risk reduction pathway by staff on B2 now Beech ward

Sally died after being stabbed by her son, who had a history of schizophrenia. The Coroner found extensive evidence of professional failures by both the health service and adult social care to get effective treatment for her son, despite Sally having raised repeated concerns.

Multiple concerns about the Trust's approach to risk assessment (including a failure to prescribe appropriate medication); the way they carried out observations; and failure to pay regard to information provided by Larry's partner, which was put on the record but ignored.

Tom sought help for depression, stating that he had suicidal thoughts. He was assessed by the MH team, but the assessment wasn't properly recorded; no discharge letter was sent to the GP, meaning that Tom didn't get the medication he needed. "It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training. It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care."

1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise. 2) A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on. 3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following: – There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment – “Discussions and assessments of risk should be clearly documented” – “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions” – There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”