9 Sep 2024 Amanda Richardson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 4 Failure of hospital systems to review and safeguard medication prescribing and administration View source Failure to search patient rooms and hospital grounds after serious illicit-drug incidents View source Inadequate security arrangements in a low secure mental health hospital View source Failure to record the nature, duration and responsible person for searches of returning patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Amanda Richardson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital systems to review and safeguard medication prescribing and administration
Wider context from the report “2. It was admitted that the prescription of ████████ at the rate of ████████mg/day was double the ████████mg/day stipulated maximum (without additional monitoring being undertaken) and was made in error. This situation went unnoticed for some six months, until her death. There was no effective system of review in the hospital in this period. The pharmacist appears to have dispensed the drug without querying the high dose. The nurses who administered the drugs did not question it. The MDT meetings which took place did not check the dose, or reflect upon its potential interaction with the several other medications prescribed. Overall, there was no effective resilience in the hospital’s systems to safeguard against drugs bring prescribed or administered in error .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to search patient rooms and hospital grounds after serious illicit-drug incidents
Wider context from the report “4. Ms Richardson died some 9 days later. Despite the seriousness of the 19.4.23 incident, no searches were carried out in her room or the hospital grounds in the period following her return . The toxicology and pathological evidence indicated that she had taken heroin shortly before her death. Her room was not searched even after her death , as assumptions were wrongly made that her death was due to a cardiac event.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Inadequate security arrangements in a low secure mental health hospital
Wider context from the report “6. The inquest was unable to establish how or when Ms Richardson obtained illicit illegal drugs. Concerns were expressed as to the adequacy of the security arrangements in this low secure mental health hospital as at April 2023.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to record the nature, duration and responsible person for searches of returning patients
Wider context from the report “3. On 19.4.23, Ms Richardson was permitted unescorted leave in the community under S.17 MHA 1983. She did not return. She did, however, voluntarily reappear at the hospital the following day, albeit under the influence of illicit drugs and alcohol. Evidence was given that nurses reported having searched Ms Richardson on her return, but no adequate written record was made to confirm the nature or duration of the search, nor by whom it was conducted , in breach of hospital policies .
” Open source report
Concerns raised 3 Delays in taking life-saving emergency equipment to the patient’s side View source Disconnect between observation policy, staff instructions and pre-printed recording forms View source Failure to record the patient’s actual presentation during observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samantha Jane BOAZMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samantha Jane Boazman, who was detained under section 3 of the Mental Health Act and living in a locked rehabilitation ward, was found unresponsive in her bathroom on 22 October 2021 and was pronounced dead later that evening. The report identified concerns about delayed access to emergency equipment and CPR, and about predictable and inadequate recording of patient observations. The inquest jury found gross neglect involving shortcomings including inadequate training, failure to remove ligature risks from bedrooms, and inadequate induction and training of temporary staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Delays in taking life-saving emergency equipment to the patient’s side
Wider context from the report “1. Emergency Response
I heard during the course of the inquest that when an alarm sounded staff would attend the location of the alarm, assess the situation and then go and collect what equipment may be necessary to deal with the emergency.
At the time of Samantha’s death there was only 1 emergency bag for the entire hospital (which had 2 wards and separate self-contained flats on the site). This has now been rectified and there is an emergency bag for every ward.
Staff partake in a drill and evidence provided to me for the purposes of Regulation 28 showed that response times of staff remain at 2 minutes to a patient’s side.
However, I was told that the emergency response still has staff attend a patient, assess and then go and collect the emergency bag, rather than taking it immediately to the patient’s side .
I was provided with evidence for the purposes of Regulation 28 by Inmind Healthcare Group which showed, for example, that in December of 2022 there were 64 incidents, 45 of which were self-harm, 2 of which were clinical incidents. 16 resulted in actual harm and a large number of those incidents concerned patients ligating.
To continue with an emergency response which delays the provision of life saving equipment to the patients’ side is unsafe and in my opinion could lead to future deaths.
The delay in providing CPR to Samantha on balance had no causative effect on her death, but it could for another patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Disconnect between observation policy, staff instructions and pre-printed recording forms
Wider context from the report “2. Observation Policy
At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of the observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing.
Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient.
Inmind Healthcare Group’s new observation Policy states:
‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice……
Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’.
Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour).
Evidence of recent observation records demonstrated that this was now practice.
However, there was a disconnect between the new policy and the pre-printed forms being used to record observations ; what staff were being instructed to do and what they were recording . This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice . The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Inmind Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to record the patient’s actual presentation during observations
Wider context from the report “2. Observation Policy
At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of the observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing.
Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient.
Inmind Healthcare Group’s new observation Policy states:
‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice……
Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’.
Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour).
Evidence of recent observation records demonstrated that this was now practice.
However, there was a disconnect between the new policy and the pre-printed forms being used to record observations; what staff were being instructed to do and what they were recording. This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice. The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace hospital observation forms with two centralised forms used across all Inmind hospitals.
Verbatim wording from the response “13. Inmind immediately reviewed the forms used at Sturdee Community Hospital and in the other hospitals run by Inmind and found staff had been using a variety of forms rather than one centralised document. All pre-existing forms have been systematically deleted from computers in the hospitals and replaced with two forms which are now available on the shared drive and used by all Inmind Hospitals. Copies of these two forms are appended: Intermittent observations (MV5) and Continuous Observations (MV6).” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Inmind Observations Policy to require centralised forms and compliance with national NHS standards.
Verbatim wording from the response “14. The Inmind Observations Policy has been updated to ensure these centralised forms are used and ensure that observations are made in line with national NHS standards.” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out regular audits of observation-record quality across all Inmind hospitals, overseen by the Group Medical Director.
Verbatim wording from the response “16. In addition to the further training provided to staff, I confirm that regular audits of the quality of the entries in observation records will be carried out by the Hospital Directors (or Deputy Hospital Directors) across all the Inmind hospitals. These audits will be overseen by the Medical Director of the Inmind Healthcare Group. Any HCA who fails to make appropriate observation entries will be spoken to and further training provided, if necessary.” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an emergency bag in every ward across all Inmind hospitals.
Verbatim wording from the response “4. HM Coroner heard evidence that at the time of Samantha’s death there was only one emergency bag for the entire hospital which caused a delay in the emergency response on the day of Samantha’s death. ████████, Chairman of Inmind and ████████, Hospital Director of Sturdee Community Hospital, gave evidence that, as a result of Inmind’s Root Cause Analysis into the circumstances of Samantha’s death, there is now an emergency bag in every ward in all Inmind hospitals.” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an emergency alarm response system using two-way radios, designated first responders, and new local protocols.
Verbatim wording from the response “8. Inmind has informed the Care Quality Commission about the development. Inmind has also perused national and NHS Trusts policies and protocols. Based on these and the best evidence available, Inmind has implemented the following:” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff attending alarms at Sturdee Community Hospital to collect the emergency bag before responding.
Verbatim wording from the response “saving equipment and could lead to future deaths. HM Coroner therefore recommended that staff should collect the emergency bag before attending the location of every alarm.” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide radio-use and emergency-response training to all staff, including competency testing through regular practice scenarios.
Verbatim wording from the response “10. Practice emergency scenarios have been carried out every two weeks to test these changes. These tests demonstrate that this system should work well in the event of a real emergency (MV3). It has been observed that there are swift responses to alarms to de-escalate patients as well as less triggering of patients’ undesirable behaviours. This has now become part of Inmind’s internal Basic Life Support training.” Source location Response from Inmind Healthcare Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train HCAs and other staff to complete meaningful observation records, followed by competency assessment.
Verbatim wording from the response “15. Further training has been provided to HCAs and other staff to ensure the completion of these observation forms is optimised so that the entries are meaningful and assist others in gathering information about the patient and any potentially escalating scenarios. After training, staff undergo a competency assessment.” Source location Response from Inmind Healthcare Group
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations