"GDPR Says Yes"

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.

Michaela was in a relationship with a prolific offender who murdered her in her home by stabbing her in the eye. The Coroner found multiple failings across a number of services, including police, probation and adult and children's social care. These included: - An inadequate assessment of the risk posed to Michaela and her children by her partner - Multiple failures to communicate between agencies - A lack of professional curiosity leading to a failure to investigate the perpetrator's mental impairment, despite clear warning signs - Failure to act on or share information received from family members. The PFD report quotes from the Coroner's full judgement, which is not available at judiciary.uk, but which is likely to add clarity about these failings and the steps needed to correct them.

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.

On 29 September 2022, Kevin was discovered deceased in his cell, having died as a result of ligature asphyxiation. He had a long history of mental ill health, paranoia and self-harm behaviours. He was on an Assessment, Care in Custody and Teamwork (ACCT) plan. However: - Information about Kevin's needs was not being shared between staff at handover - The ACCT plan itself was unavailable to staff on the day of his death - a day known to be a trigger date for Kevin - as it had been removed for quality assurance - Staff were not trained in ACCT observations, and some were simply completing "signs of life" checks" - After Kevin's death, records were falsified to state that ACCT checks had been carried out

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.