UK Inquiry Tracker

Ryan Chapman

PFD Report Historic (No Identified Response) Ref: 2014-0048

Date of Report 31 January 2014

Coroner Penelope Schofield

Coroner Area West Sussex

Response Deadline est. 28 March 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.

View full coroner's concerns

In the circumstances it is my statutory duty to make this report to you: During the course of evidence it was shown that there a lack of understanding by staff of Trust's Leave for Non detained patients Policy: Staff seemed unclear as whether or not this policy should be applied when patients left the ward to attend activities within the hospital grounds It if was to be applied then it was not strictly adhered to in Ryan's case_ The Nurse in Charge did not carry out an assessment as required under Para 4.5,, of Ryan at the time he left the ward.
3. Staff appeared to be unclear as to the role of Support worker with regards to whether or not are able to fulfil the role %f an escort for patients leaving the ward: The Peer support worker who gave evidence indicated that she did not consider herself an escort but she was responsible adult who accompanied patients. In Ryan's case the Doctor had approved his leave only when accompanied by an escort The terminology used in the policy causes this confusion. Ryan's Risk assessment and Health Care Plan was not completed within the required period. This plan was completed two days after it should been. There was lack of written information provided to families by the Hospital on admission to them support their_family memberIt appears that this information is at present only_given 5981872.1 being got May the the Peer they have help to the patient In addition the family were not provided with a copy of the Ryan's care plan. There appeared to be a general lack of security on ward with regards to visitors: There was no consistent signing in procedure and family members could be on the ward without there a record being kept

Sent To

Sussex Partnership NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 28 Mar 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 23" May 2013 commenced an investigation into the death of Ryan Chapman, born on 9th March 1984, being 29 years of age An Inquest was opened on 23rd May 2013 and was concluded on 16th January 2014

Circumstances of the Death

On 14"h May 2013 Ryan was admitted, as an informal patient; onto the Rowan Ward at the Meadowfield Hospital, Worthing suffering from an undiagnosed mental health condition: On 20" May 2013 Ryan was accompanied by a peer support worker from the ward to pottery class When he to the reception area of the hospital he took off, left the hospital and ran towards the A27 road. Witnesses then saw Ryan running along the pavement alongside the road When for no reason he changed direction and ran straight out in front of the articulated lorry. It appeared that this was a deliberate act Ryan subsequently died on 22nd 2013 at Southampton Hospital from the injuries he had sustained. The cause of death that was reported was that he had died from 1a Catastrophic brain injury and 1b Polytrauma_

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation, Sussex Partnership NHS Foundation Trust can take this action