Dear Miss Hamilton-Deeley Re Danuta Corbett am writing further to your report; written pursuant to the Coroners & Justice Act 2009 and the Coroner's (Investigations) Regulations 2013, regarding the Inquest in to the sad death of Danuta Corbett. The concerns your report highlight relate to our policy for leave for non detained patients and, specifically, how staff managed the leave that had been agreed for Danuta from November 2013, and how the plans made on 4 November 2013 were recorded_ We acknowledge that despite having planned to support Danuta to return home over that weekend to collect some belongings, this did not happen: The primary reason was due to difficulty releasing a member of staff during what was an extremely busy weekend. Clinicians understand that leave can be an integral part of a person's care plan and so when a patient needs to be supported by a member of staff then effort is made to facilitate this_ It is with much regret that the record keeping on Monday 4 November 2013 was so poor: Neither the detailed assessment carried out by the consultant during the ward review, nor the assessment completed by the nurse in charge shortly afterwards, were properly documented. This is a requirement of the leave policy, and a fundamental part of good clinical practice. The consultant psychiatrist has learnt a great deal from this experience. She now carefully reviews the notes taken during ward review; which are typically scribed by the junior doctor present: As you heard at the Inquest, the nurse did not make a note at all This was because the incident happened shortly after her assessment and she was so distressed by what happened that she went home and did not return to work for several It is quite normal for nursing staff to write in patient notes toward end of the shift. However, on her return the nurse ought to have written a clearly marked retrospective note_ She did not do this after being advised at the time by the acting Matron that this was not appropriate We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed. Finally, it is clear that the communication with the agency nurse who was accompanying Danuta should have been much better. The nurse responsible acknowledges this and will always ensure proper handovers take place in the future. very every days. the

It seems unlikely that of the shortcomings highlighted by this very sad case would have prevented the tragic outcome_ However all the staff involved in Danuta's care have carefully reflected on what happened and used the learning to improve their practice_ hope this information is helpful and confirm that we have no objections to it shared or published by the Chief Coroner: