UK Inquiry Tracker

Alison Draper

PFD Report Historic (No Identified Response) Ref: 2015-0205

Date of Report 29 May 2015

Coroner Maria Voisin

Coroner Area Avon

Response Deadline est. 24 July 2015

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent observations.

View full coroner's concerns

_ heard evidence that there is no policy in relation to what staff should do ifa patientlservice user is not found within the 10 minute observation period: would ask that you consider whether guidance should be issued as to the steps that staff should take. would also request that you consider the hourly check as detailed above_ appears in this case that one member of staff was asked to check 19 patients, two of whom were on 10 minute observations Please consider whether guidance be given as to how to manage and balance the hourly checks with those on 10 minute observations_

Sent To

Avon and Wiltshire NHS Partnership Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 24 Jul 2015

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 10hh September 2014 an investigation into the death of Alison Jane DRAPER, Aged 45 commenced. The investigation concluded at the end of the inquest on 28h May 2015. The conclusion of the inquest was: Medical Cause_of Death la Hypoxic brain injury Ib Neck ligature Ic Mental health issues Conclusion Narrative Alison Draper was found ligatured in her bedroom whilst a patient on Juniper Ward, she died from the injuries she sustained, her intention is unknown: She was on 10 minute observations at the time and should have been checked at 7pm she was not found in her bedroom until approximately 7.12pm which was 20 minutes approximately from the previous check; this resulted in a lost opportunity to render medical care , attention or treatment

Circumstances of the Death

Ms. Draper had a history of mental health problems over a number years which included several attempts to self-harm and take her life. On 8th August 2014 she was admitted to Elizabeth Casson House at Callington Road Hospital, she was detained under Section 2 of the Mental Health Act, During this admission she made 8 attempts to take her life by ligature: The risk of self-harmlsuicide was described by her Consultant as chronic and impulsive. On 5lh September 2014 Ms_ Draper was stepped down from the Psychiatric Intensive Care unit to Juniper Ward (an open acute unit)_ On 7lh September a Health Care Assistant was tasked with carrying 10 minutes observations on Ms. Draper: She last observed her at 18.50 in the garden: At the 7pm check the same Health Care Assistant was also tasked with carrying out the hourly checks for all 19 patients on the ward, two of whom were on 10 minute observations, one of whom was Ms. Draper: It is unclear how the checks_ were actually carried out as the_witness could not remember and being out but at approximately 7:10/7:12 pm she asked for assistance from two other members of staff Ms Draper was found in her own bedroom having ligatured herself: Ms. Draper was taken to Hospital but suffered an un-survivable hypoxic brain injury

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: