Martyn Watkins
PFD Report
Partially Responded
Ref: 2016-0409
Coroner's Concerns (AI summary)
Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
View full coroner's concerns
(1) The care and treatment provided by the Trust to Mr. Watkins should be reviewed at the earliest opportunity in the light of the findings of the jury at the Inquest and the Trust’s own internal management report and root cause analysis report.
(2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed.
(3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.
(4) The CQC should satisfy themselves that the arrangements and facilities for the provision of care and treatment of service users on Aspen Ward, now and in the future, are such as to ensure those service users can be provided with safe care and treatment.
(2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed.
(3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.
(4) The CQC should satisfy themselves that the arrangements and facilities for the provision of care and treatment of service users on Aspen Ward, now and in the future, are such as to ensure those service users can be provided with safe care and treatment.
Responses
Action Taken
The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract. (AI summary)
The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract. (AI summary)
View full response
Dear HM Coroner
Prevention of future death report following inquest into the death of Mr Martyn Watkins. Thank you for your letter dated 14 November 2016, enclosing the above Report.
We are also grateful for the extension of time granted for this response (until 6 February 2017).
As you are already aware the Provider which is registered with CQC and has overall responsibility for services provided at the relevant location (Callington Road Hospital) is Avon and Wiltshire NHS Partnership Trust.
CQC became aware of the sad death of Mr Watkins on 16 May 2016, when the Trust shared a management report with us through an online information sharing system. The report had been uploaded to the system on 12 May 2016. This was received by the lead CQC inspector for the Trust.
We noted that Mr Watkins had been detained under Section 2 of the Mental Health Act (MHA). We had not received a statutory notification of a death of a detained patient so we contacted our MHA office in Nottingham to check. Once it was confirmed that we had not received notification we called the MHA Administrator at the Trust to ask why we had not been notified. We were told that Mr Watkins had been discharged from his section on transfer to Southmead Hospital.
At the time we planned to inspect older adults’ inpatient services between 16 and 27 May 2016 as part of our comprehensive inspection programme. We asked the HSCA Citygate Gallowgate Newcastle upon Tyne NE1 4PA
inspector leading the team to follow this up when they visited Aspen Ward. During the inspection we found that the Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward.
However, the rating for the overall core service (older people’s mental health inpatient wards) was “requires improvement” because:
• There were not sufficient staff numbers to meet the needs of people using the services. There was a high level of qualified nurse vacancies on some wards with no psychology input.
• Levels of emergency response training and practical patient handling training were low.
• Staff did not consistently adhere to Mental Health Act legislation and standards described in the Mental Health Act (MHA) 1983 code of practice.
• Staff completed mental capacity assessments but did not document decision specific assessments.
• Staff were inconsistent when reporting of incidents.
• Staff did not always follow agreed actions or involve patients in care plans.
• Staff did not all use the health of the nation outcome scales for over 65s. They were not consistently monitoring patient’s outcomes.
• Multidisciplinary team meetings did not all have a full range of professions.
• The standard of the environments was variable. They were not all “dementia friendly”. Safety alarms were of variable quality or were not available. Some bedroom windows did not protect patient’s privacy and some patients slept in dormitories. Our response to the matters raised in the Regulation 28 letter is as follows:
1. As a regulator CQC has both criminal and civil enforcement powers. There are two primary reasons why we may use our enforcement powers. First to protect people who use regulated services from harm and the risk of harm and to ensure they receive health and social care services of an appropriate standard. Secondly to hold providers to account for failures in how the service is provided.
Further and more specific detail is included in our published Enforcement Policy, a copy of which is available free of charge on our web-site (http://www.cqc.org.uk/content/enforcement-policy)
2. The civil enforcement powers are aimed at ensuring that any ongoing risk to patients, such as those detailed in the Regulation 28 Report are appropriately identified, and that where risks are still found to exist that we as a regulator take proportionate action to ensure that the Provider becomes compliant with the relevant
legal requirements which ensure patient safety. Such action can be anything from formal ‘Requirement Notices’ / ‘Warning Notices’ to imposing urgent conditions on the Registration of a Provider and in extreme circumstances suspending or cancelling the Registration of a Provider.
In relation to this particular Trust we are exercising our statutory powers to request information and documentation to identify and determine the level of risk to patients. As part of this process we have also already exercised our statutory powers of Inspection (on 10 January 2017) and we are currently liaising with the Trust to ensure that patients are properly protected. The Inspection and the associated regulatory actions are looking at not just the matters identified in the Regulation 28 Report but also wider issues which may impact on safe care and treatment for patients.
3. The criminal enforcement powers which we have are aimed at holding Providers to account where there has, for example, been a failure on the part of a Provider in terms of safe care and treatment, and where those failure(s) have then resulted in avoidable harm to a patient (whether physical or psychological), or alternatively where the failure(s) expose a patient to serious risk of such harm. We do not have regulatory powers to take action against individuals (e.g. clinical / healthcare staff) where there are individual failings (as those would be dealt with by other professional bodies). However this does not mean that we will not look at individual failings to determine why they occurred and specifically consider whether a Provider could/should have taken action to ensure that such failings were avoided altogether.
In relation to this particular Trust we have noted that the indication from the Trust in the Root Cause Analysis (RCA) Investigation Report (Reference: 2016/8370) appears to be that the sad death of Mr Watkins was caused by an individual failing to remove from his possession a belt. Whilst we are grateful to receive the RCA as well as the ‘Management Report on Red Graded Incidents dated 31/03/2016’ from the Trust, we are reviewing for ourselves the circumstances which led to the sad death of Mr Watkins and in accordance with our regulatory remit will make our own judgments in that regard.
We are happy to keep HM Coroner updated on the progress of our regulatory actions should HM Coroner deem this to be appropriate.
Should you require any further information please do not hesitate to contact us:
By email:
HSCAfurtherinformation@cqc.org.uk Cc’d to:
By post:
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Please include the reference number MRR1-3078722466 on all correspondence.
Thank you in advance for your assistance.
Prevention of future death report following inquest into the death of Mr Martyn Watkins. Thank you for your letter dated 14 November 2016, enclosing the above Report.
We are also grateful for the extension of time granted for this response (until 6 February 2017).
As you are already aware the Provider which is registered with CQC and has overall responsibility for services provided at the relevant location (Callington Road Hospital) is Avon and Wiltshire NHS Partnership Trust.
CQC became aware of the sad death of Mr Watkins on 16 May 2016, when the Trust shared a management report with us through an online information sharing system. The report had been uploaded to the system on 12 May 2016. This was received by the lead CQC inspector for the Trust.
We noted that Mr Watkins had been detained under Section 2 of the Mental Health Act (MHA). We had not received a statutory notification of a death of a detained patient so we contacted our MHA office in Nottingham to check. Once it was confirmed that we had not received notification we called the MHA Administrator at the Trust to ask why we had not been notified. We were told that Mr Watkins had been discharged from his section on transfer to Southmead Hospital.
At the time we planned to inspect older adults’ inpatient services between 16 and 27 May 2016 as part of our comprehensive inspection programme. We asked the HSCA Citygate Gallowgate Newcastle upon Tyne NE1 4PA
inspector leading the team to follow this up when they visited Aspen Ward. During the inspection we found that the Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward.
However, the rating for the overall core service (older people’s mental health inpatient wards) was “requires improvement” because:
• There were not sufficient staff numbers to meet the needs of people using the services. There was a high level of qualified nurse vacancies on some wards with no psychology input.
• Levels of emergency response training and practical patient handling training were low.
• Staff did not consistently adhere to Mental Health Act legislation and standards described in the Mental Health Act (MHA) 1983 code of practice.
• Staff completed mental capacity assessments but did not document decision specific assessments.
• Staff were inconsistent when reporting of incidents.
• Staff did not always follow agreed actions or involve patients in care plans.
• Staff did not all use the health of the nation outcome scales for over 65s. They were not consistently monitoring patient’s outcomes.
• Multidisciplinary team meetings did not all have a full range of professions.
• The standard of the environments was variable. They were not all “dementia friendly”. Safety alarms were of variable quality or were not available. Some bedroom windows did not protect patient’s privacy and some patients slept in dormitories. Our response to the matters raised in the Regulation 28 letter is as follows:
1. As a regulator CQC has both criminal and civil enforcement powers. There are two primary reasons why we may use our enforcement powers. First to protect people who use regulated services from harm and the risk of harm and to ensure they receive health and social care services of an appropriate standard. Secondly to hold providers to account for failures in how the service is provided.
Further and more specific detail is included in our published Enforcement Policy, a copy of which is available free of charge on our web-site (http://www.cqc.org.uk/content/enforcement-policy)
2. The civil enforcement powers are aimed at ensuring that any ongoing risk to patients, such as those detailed in the Regulation 28 Report are appropriately identified, and that where risks are still found to exist that we as a regulator take proportionate action to ensure that the Provider becomes compliant with the relevant
legal requirements which ensure patient safety. Such action can be anything from formal ‘Requirement Notices’ / ‘Warning Notices’ to imposing urgent conditions on the Registration of a Provider and in extreme circumstances suspending or cancelling the Registration of a Provider.
In relation to this particular Trust we are exercising our statutory powers to request information and documentation to identify and determine the level of risk to patients. As part of this process we have also already exercised our statutory powers of Inspection (on 10 January 2017) and we are currently liaising with the Trust to ensure that patients are properly protected. The Inspection and the associated regulatory actions are looking at not just the matters identified in the Regulation 28 Report but also wider issues which may impact on safe care and treatment for patients.
3. The criminal enforcement powers which we have are aimed at holding Providers to account where there has, for example, been a failure on the part of a Provider in terms of safe care and treatment, and where those failure(s) have then resulted in avoidable harm to a patient (whether physical or psychological), or alternatively where the failure(s) expose a patient to serious risk of such harm. We do not have regulatory powers to take action against individuals (e.g. clinical / healthcare staff) where there are individual failings (as those would be dealt with by other professional bodies). However this does not mean that we will not look at individual failings to determine why they occurred and specifically consider whether a Provider could/should have taken action to ensure that such failings were avoided altogether.
In relation to this particular Trust we have noted that the indication from the Trust in the Root Cause Analysis (RCA) Investigation Report (Reference: 2016/8370) appears to be that the sad death of Mr Watkins was caused by an individual failing to remove from his possession a belt. Whilst we are grateful to receive the RCA as well as the ‘Management Report on Red Graded Incidents dated 31/03/2016’ from the Trust, we are reviewing for ourselves the circumstances which led to the sad death of Mr Watkins and in accordance with our regulatory remit will make our own judgments in that regard.
We are happy to keep HM Coroner updated on the progress of our regulatory actions should HM Coroner deem this to be appropriate.
Should you require any further information please do not hesitate to contact us:
By email:
HSCAfurtherinformation@cqc.org.uk Cc’d to:
By post:
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Please include the reference number MRR1-3078722466 on all correspondence.
Thank you in advance for your assistance.
Sent To
- Avon and Wiltshire Mental Health Partnership NHS Trust
- Care Quality Commission
Response Status
Linked responses
1 of 2
56-Day Deadline
9 Jan 2017
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 6th April 2016 I commenced an investigation into the death of Mr. Martyn Watkins aged 65 years. The investigation concluded at the end of the inquest on 11th November 2016. The conclusion of the jury was that the medical cause of death was I(a) Hypoxic brain injury; I(b) Hanging, and their conclusion was that of: “Suicide - facilitated by access to means, resulting from inadequate checks to remove ligature risks from his person and a failure to identify fundamental risks in the environment”. ! 1
Circumstances of the Death
During December 2015 Mr. Watkins suffered a deterioration in his mental health related in part to concerns he had with the health of close members of his family and his own retirement from employment as an accountant. He came under the care of the mental health services and was seen by members of both the Primary Care Liaison Service (PCLS) and the Intensive Support Team (IST). Mr. Watkins had contact both by face-to-face visits at home and also telephone contact with members of those teams on a regular basis. The plan was to try and support Mr. Watkins and his family at home so as to facilitate his recovery. However, he developed suicidal ideation and required two brief hospital admissions one following an intentional overdose of medication. His family became increasingly concerned at the risk Mr. Watkins posed to himself from suicide such that they removed all medication from his home, including that of his wife, and gave him doses of his medication as required. However, the family were finding it extremely difficult to manage the situation and keep Mr. Watkins safe. There was no real improvement in his presentation and there were significant concerns regarding his thoughts of suicide. By March 2016 the family reported they were at their ‘wits-end’. On 22nd March 2016 Mr. Watkins daughter contacted, via social media, the Associate Practitioner on Aspen Ward, Callington Road Hospital which is part of the Avon & Wiltshire Mental Health Partnership NHS Trust (‘the Trust’) in an attempt to seek any assistance to help her father. These two individuals knew of each other through a mutual third party. The Associate Practitioner contacted Mr. Watkins’ daughter and offered to speak with a consultant psychiatrist on Aspen Ward. The Associate Practitioner duly spoke with the consultant psychiatrist on the morning of 23rd March 2016 who in turn agreed to provide a second opinion if appropriate. Mr. Watkins’ daughter was contacted again that morning by the Associate Practitioner seeking further information. However, by this time a Mental Health Act (MHA) Assessment had been arranged and this was planned for that same day. On 23rd March 2016 the Associate Practitioner explained the situation to the Ward Manager of Aspen Ward who agreed that Mr. Watkins could be admitted to that ward if his admission and detention was required. The Ward Manager contacted the IST advising that Mr. Watkins could be admitted to Aspen Ward subject to a bed being available. The MHA assessment was undertaken as planned by the Approved Mental Health Professional (AMHP) and two consultant psychiatrists and it was determined that he needed to be admitted to hospital under s.2 Mental Health Act 1983. The Section 12 approved psychiatrist told the Inquest that Mr. Watkins was at high risk of suicide and at risk of impulsive acts. During the afternoon of the 23rd March 2016 the ward was advised that the second registered mental health nurse due to work the late shift that day was sick and as a result that shift would be staffed by only one Registered Nurse (herself undergoing her preceptorship) together with the Associate Practitioner, Health Care Assistants and a student nurse. Prior to the Ward Manager going off duty at around 17:30 hours the Registered Nurse advised the Ward Manager that she would not be able to accept any new admissions during her shift since she would be the only Registered Nurse on duty. Sometime later the Associate Practitioner advised the Registered Nurse that Mr. Watkins was going to be admitted to the ward and he arrived at around 20:20 hours. The Registered Nurse was unsure what had been agreed between the Associate Practitioner and the Ward Manager with regard to Mr. Watkins’ admission to the ward. However, the Associate Practitioner advised that she was able to admit him to the ward. ! 2
On his arrival on the ward Mr. Watkins’ stated he wished to go directly to his room and he was taken there by the Associate Practitioner. The Registered Nurse told the Inquest that she did not see Mr. Watkins at all during her shift as she was mostly attending to duties in the office. The AMHP also attended Aspen Ward and saw the Registered Nurse but did not speak to the Associate Practitioner. Aspen Ward is a ward designed for older patients and Mr. Watkins was admitted to a room intended originally for those patients requiring palliative care. In the room, in addition to the service user’s bed, was a fold up bed constructed of an aluminium frame and wooded slats, which was intended for use by a relative of the service user. This bed was fixed and located within a wooden cupboard and folded flat against the wall. The bed could be pulled down when required for use. The cupboard was believed to have been locked although no witness at the Inquest confirmed they had checked the cupboard was locked at the time. Some witnesses from the ward were unaware there was such a bed within this cupboard. The Associate Practitioner went through the admission procedure with Mr. Watkins. She told the Inquest that she went through his bag carefully noting its contents and removed some items she considered could be potentially used as a ligature. The Associate Practitioner, in evidence, told the court that she did not enquire of Mr. Watkins as to what items he had on his person nor did she carry out any search of Mr. Watkins for items which might have posed a risk to him. She told the court that she did not know he was wearing a belt and therefore Mr. Watkins retained his belt. Mr. Watkins was placed on 10-minute observations by the Associate Practitioner. Following the later incident the observation chart went missing and has not been found. Those witnesses, who had carried out some of the observations, who gave evidence at the Inquest confirmed they carried out their observations at the required times. During his time on Aspen Ward it appears Mr. Watkins remained fully clothed at all times. He was seen overnight to be sleeping on his bed and was fully clothed. Overnight he was seen by the duty doctor to be clerked on to the ward and for his medication to be prescribed. No physical examination was carried out at that time. The following morning, the 24th March 2016, Mr. Watkins was seen by the consultant psychiatrist who did not notice the belt. He was also seen by a ward doctor who conducted a physical examination including an abdominal examination. That doctor did not give evidence at the Inquest. One Healthcare Assistant (1) who carried out some of the 10-minute observations reported that Mr. Watkins would not speak and did not make eye contact. Another Health Care Assistant (2) was able to engage in some conversation with Mr. Watkins. At around 12:15 hours the Health Care Assistant (2) saw Mr. Watkins in his room inviting him to the dining room for lunch. Mr. Watkins declined and also did not wish to have any food in his room. Shortly after 13:00 hours Health Care Assistant (2) went to Mr. Watkins’ room for a 10-minute observation. He saw the doors of the cupboard containing the bed open and Mr. Watkins hanging from his belt used as a ligature which had been secured to the top aluminium rail of the bed. He sounded the site-wide alarm and lowered Mr. Watkins to the floor. Other members of staff quickly attended and CPR was commenced. The paramedics and air ambulance were summoned. Mr. Watkins was unconsciousness and he was taken to Southmead Hospital, Bristol. Despite treatment on the Intensive Care Unit he never regained consciousness and died in hospital on 1st April 2016. The witnesses who attended the Inquest stated they had not seen Mr. Watkins wearing his belt. Police officers and CSI attended Aspen Ward. A police officer states he was shown the observation chart at that time by the Ward Manager and confirmed there were entries at the appropriate times. The doors of the cupboard containing the bed did not appear to have been forced. The police officers were satisfied there was no third party involvement in Mr. Watkins’ hanging. ! 3
During the course of the Inquest the evidence revealed that:
1. There was no documented discussion between teams of the purpose of admission and concerns about risk in the community.
2. The room used to accommodate Mr. Watkins was inappropriate and unsafe given his high risk suicide.
3. There had been no risk assessment of the cupboard and fold-up bed with respect to ensuring the cupboard was secure and the presence of ligature points.
4. On arrival on the ward the standard procedure for admission was not followed with no documentation of the admission by a registered professional.
5. No enquiries were made, and no proper search was made, of Mr. Watkins to ensure he had no items on his person which could pose a risk to him although items in his bag had been removed.
6. There was a lack of communication of the specific risks in the progress notes and 72-hour care plan created by the Associate Practitioner.
7. The risk of hanging was not considered as Mr. Watkin’s had only expressed thoughts of taking an overdose before admission to hospital. CORONER’S CONCERNS During 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The care and treatment provided by the Trust to Mr. Watkins should be reviewed at the earliest opportunity in the light of the findings of the jury at the Inquest and the Trust’s own internal management report and root cause analysis report. (2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed. (3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity. (4) The CQC should satisfy themselves that the arrangements and facilities for the provision of care and treatment of service users on Aspen Ward, now and in the future, are such as to ensure those service users can be provided with safe care and treatment.
On his arrival on the ward Mr. Watkins’ stated he wished to go directly to his room and he was taken there by the Associate Practitioner. The Registered Nurse told the Inquest that she did not see Mr. Watkins at all during her shift as she was mostly attending to duties in the office. The AMHP also attended Aspen Ward and saw the Registered Nurse but did not speak to the Associate Practitioner. Aspen Ward is a ward designed for older patients and Mr. Watkins was admitted to a room intended originally for those patients requiring palliative care. In the room, in addition to the service user’s bed, was a fold up bed constructed of an aluminium frame and wooded slats, which was intended for use by a relative of the service user. This bed was fixed and located within a wooden cupboard and folded flat against the wall. The bed could be pulled down when required for use. The cupboard was believed to have been locked although no witness at the Inquest confirmed they had checked the cupboard was locked at the time. Some witnesses from the ward were unaware there was such a bed within this cupboard. The Associate Practitioner went through the admission procedure with Mr. Watkins. She told the Inquest that she went through his bag carefully noting its contents and removed some items she considered could be potentially used as a ligature. The Associate Practitioner, in evidence, told the court that she did not enquire of Mr. Watkins as to what items he had on his person nor did she carry out any search of Mr. Watkins for items which might have posed a risk to him. She told the court that she did not know he was wearing a belt and therefore Mr. Watkins retained his belt. Mr. Watkins was placed on 10-minute observations by the Associate Practitioner. Following the later incident the observation chart went missing and has not been found. Those witnesses, who had carried out some of the observations, who gave evidence at the Inquest confirmed they carried out their observations at the required times. During his time on Aspen Ward it appears Mr. Watkins remained fully clothed at all times. He was seen overnight to be sleeping on his bed and was fully clothed. Overnight he was seen by the duty doctor to be clerked on to the ward and for his medication to be prescribed. No physical examination was carried out at that time. The following morning, the 24th March 2016, Mr. Watkins was seen by the consultant psychiatrist who did not notice the belt. He was also seen by a ward doctor who conducted a physical examination including an abdominal examination. That doctor did not give evidence at the Inquest. One Healthcare Assistant (1) who carried out some of the 10-minute observations reported that Mr. Watkins would not speak and did not make eye contact. Another Health Care Assistant (2) was able to engage in some conversation with Mr. Watkins. At around 12:15 hours the Health Care Assistant (2) saw Mr. Watkins in his room inviting him to the dining room for lunch. Mr. Watkins declined and also did not wish to have any food in his room. Shortly after 13:00 hours Health Care Assistant (2) went to Mr. Watkins’ room for a 10-minute observation. He saw the doors of the cupboard containing the bed open and Mr. Watkins hanging from his belt used as a ligature which had been secured to the top aluminium rail of the bed. He sounded the site-wide alarm and lowered Mr. Watkins to the floor. Other members of staff quickly attended and CPR was commenced. The paramedics and air ambulance were summoned. Mr. Watkins was unconsciousness and he was taken to Southmead Hospital, Bristol. Despite treatment on the Intensive Care Unit he never regained consciousness and died in hospital on 1st April 2016. The witnesses who attended the Inquest stated they had not seen Mr. Watkins wearing his belt. Police officers and CSI attended Aspen Ward. A police officer states he was shown the observation chart at that time by the Ward Manager and confirmed there were entries at the appropriate times. The doors of the cupboard containing the bed did not appear to have been forced. The police officers were satisfied there was no third party involvement in Mr. Watkins’ hanging. ! 3
During the course of the Inquest the evidence revealed that:
1. There was no documented discussion between teams of the purpose of admission and concerns about risk in the community.
2. The room used to accommodate Mr. Watkins was inappropriate and unsafe given his high risk suicide.
3. There had been no risk assessment of the cupboard and fold-up bed with respect to ensuring the cupboard was secure and the presence of ligature points.
4. On arrival on the ward the standard procedure for admission was not followed with no documentation of the admission by a registered professional.
5. No enquiries were made, and no proper search was made, of Mr. Watkins to ensure he had no items on his person which could pose a risk to him although items in his bag had been removed.
6. There was a lack of communication of the specific risks in the progress notes and 72-hour care plan created by the Associate Practitioner.
7. The risk of hanging was not considered as Mr. Watkin’s had only expressed thoughts of taking an overdose before admission to hospital. CORONER’S CONCERNS During 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The care and treatment provided by the Trust to Mr. Watkins should be reviewed at the earliest opportunity in the light of the findings of the jury at the Inquest and the Trust’s own internal management report and root cause analysis report. (2) The CQC should satisfy themselves that any and all deficiencies in the care provided to Mr. Watkins and generally on Aspen Ward have been identified and addressed. (3) The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity. (4) The CQC should satisfy themselves that the arrangements and facilities for the provision of care and treatment of service users on Aspen Ward, now and in the future, are such as to ensure those service users can be provided with safe care and treatment.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.