Liam Hardy
PFD Report
Historic (No Identified Response)
Ref: 2014-0307
Coroner's Concerns (AI summary)
The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially altering care decisions.
View full coroner's concerns
Thc &s follows. The nurse who assessed Liam after an episode of self harm was unaware of some of the significant events in Liam's history_She explained that the RiQ system (an not electronic patient record system used in many Trusts) did not up or summarise such events or primary concerns and issues in a single place, and there was insufficient time to read all of the notes (which might be voluminous) before seeing a patient. Had she been aware of the full history her actions may have been different in Liam's case, but her comments about the RiO system were general, and the difficulties are apparently encountered even today:
Sent To
- South West London and St George’s Mental Health Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
28 Aug 2014
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 13th June 2014 concluded an Inquest into the death of Liam Hardy, a 15 year old schoolboy: The medical cause of death was hanging, and recorded a narrative conclusion as follows: At about 9 pm on 19"h November 2012 at his grandfather's home (address redacted) .Liam became upset and agitated while exchanging text messages. He tied his school tie around his neck and attached the other end to the upper part of a bunk bed He sat 0n the lower bunk and the ligature caused him to lose consciousness. On the balance of probability he did not intend to die. His actions were in part because his complex behavioural and emotional problems were not adequately or appropriately assessed or managed by social and mental healthcare services, and the risk to his life by acts of self harm was not recognised or adequately managed. There were failures to fully share or access information, and significant events were dealt with in a timely fashion or at all. The services placed too much reliance on addressing his needs through the family therapy service who failed to acknowledge that their intervention was not effective in addressing Liam needs. Other agencies did not appreciate the role and limitations of the family therapy service with the consequence that alternative andlor additional measures to protect Liam were not fully explored or considered
Circumstances of the Death
Please see the conclusion set out in paragraph 3. Further information can be provided if required
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
Inquest Conclusion
At about 9 pm on 19"h November 2012 at his grandfather's home (address redacted) .Liam became upset and agitated while exchanging text messages. He tied his school tie around his neck and attached the other end to the upper part of a bunk bed He sat 0n the lower bunk and the ligature caused him to lose consciousness. On the balance of probability he did not intend to die. His actions were in part because his complex behavioural and emotional problems were not adequately or appropriately assessed or managed by social and mental healthcare services, and the risk to his life by acts of self harm was not recognised or adequately managed. There were failures to fully share or access information, and significant events were dealt with in a timely fashion or at all. The services placed too much reliance on addressing his needs through the family therapy service who failed to acknowledge that their intervention was not effective in addressing Liam needs. Other agencies did not appreciate the role and limitations of the family therapy service with the consequence that alternative andlor additional measures to protect Liam were not fully explored or considered
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.