Darren Linfoot
PFD Report
Historic (No Identified Response)
Ref: 2015-0089
Coroner's Concerns (AI summary)
Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.
View full coroner's concerns
(1) The evidence was that a variety of drugs and medications are dispensed from the hospital’s in-house pharmacy for use of individual patients on the individual wards. Only controlled drugs are audited and their whereabouts monitored. Among others, Opiate drugs are classed as non-controlled and are therefore not audited. There is a real risk that potent medication could go unaccounted for and could end up in the possession of patients.
(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations. It is suggested that a consistent method is identified and appropriate training is provided.
(3) Nursing staff also gave inconsistent evidence about the duties of the radio nurse on the admissions ward. There appeared to be a need for consistency and appropriate training.
(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations. It is suggested that a consistent method is identified and appropriate training is provided.
(3) Nursing staff also gave inconsistent evidence about the duties of the radio nurse on the admissions ward. There appeared to be a need for consistency and appropriate training.
Sent To
- West London Mental Health NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
4 May 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 the 4th March 2015 I concluded an Inquest into the death of Darren Linfoot, a thirty-three year old detained patient at Broadmoor Hospital. The Inquest was heard before a Jury.
Circumstances of the Death
On the 18th December 2011 Darren Linfoot was declared deceased at Frimley Park Hospital, Surrey. He had been a patient at Broadmoor Hospital since the 17th November 2011 and he was found unresponsive in his room in the hospital by nursing staff. A post mortem examination found a cause of death of Lobar Pneumonia to which Dihydrocodeine Toxicity contributed.
Copies Sent To
of Mr Linfoot
Peter J. Bedford Senior Coroner for Berkshire
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.