This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 21st November 2012 I commenced an investigation into the death of Neil James Carter date of birth 13/03/1975. The investigation concluded at the end of the inquest on 15th December 2013. The conclusion of the inquest was “Mr Carter took his own life on the 20th November 2012 by jumping in front of a train whilst still an inpatient at the Priory Hospital Roehampton. There were gross failures in his care, notably the failure to perform basic observations followed by deliberate falsification of the record. These led cumulatively to a missed opportunity to realise he was missing, a missed opportunity to search early for him and missed opportunity to offer life saving interventions”. The medical cause of death was given as 1a. Multiple Injuries.
Circumstances of the death
Mr Carter took his own life on the 20th November 2012 by jumping in front of a train at Turnham Green Underground Station whilst still an inpatient at the Priory Hospital Roehampton.
Coroner’s concerns
(1) There were repeated failures to perform basic nursing observations (2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act. (3) There was a deliberate falsification of the nursing record.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised6
Failure of staff to accept the authority of the nurse in charge
Failure of management to listen or act on reported issues
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17
Action
Incorporate ward staffing levels and skill mix into ongoing provider monitoring and the next inspection.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
Action
Conduct a joint unannounced inspection assessing medicines management and staffing compliance actions.
Stated byCare Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Include ward layout and its impact on patient care in planning and execution of the next hospital inspection.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
Action
Conduct an unannounced follow-up inspection assessing emergency procedures, observation policies, staff training and completion of earlier compliance actions.
Stated byCare Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Conduct an unannounced joint compliance inspection of The Priory Hospital Roehampton and require remedial action for identified non-compliance.
Stated byCare Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Assess observation training and continue monitoring observation information and policy implementation to inform future inspections.
Stated byCare Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2014.
Action
Use information about alleged nursing-record falsification to inform planning and delivery of the next inspection.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
Action
Undertake an unannounced inspection within four months covering reported concerns, additional regulatory concerns and new intelligence, coordinated with Mental Health Act monitoring.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
Action
Continue monitoring ward staffing levels and skill mixes to ensure they remain appropriate.
Stated byPriory GroupStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2014.
Action
Conduct weekly four-week-cycle Quality Walk Rounds, including checks of patient observations and care plans, with results reviewed through clinical governance.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Establish a local Roehampton Human Resources function with trained staff to support staff-management responsibilities.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Review the Priory Healthcare Division Observation and Engagement Policy.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Separate Garden Wing into two wards with dedicated managers, nursing teams, therapists and activity coordinators.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Strengthen supervision and appraisal arrangements to identify and manage authority-related issues more rapidly.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Embed daily hospital monitoring visits to wards to check patient care and address immediate staff concerns.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Change the Roehampton staff induction programme to improve compliance with patient observations.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Action
Hold monthly staff meetings with hospital management to exchange feedback on safety, quality and compliance.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4
Position
No evidence of deliberate nursing-record falsification was identified during inspections.
Stated byCare Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Alleged deliberate record falsification may require referral to the relevant professional regulatory body, such as the NMC or GMC.
Stated byCare Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Deliberate record falsification is difficult to identify through routine monitoring or inspections unless reported by staff, patients or relatives.
Stated byCare Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The two wards are sufficiently staffed and skilled, with separate management and ongoing monitoring of staffing levels and skill mix.
Stated byPriory GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9
1
Deliver a thematic programme on experiences and outcomes during mental-health crises and publish a national report.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
2
Work with key partners in developing the Mental Health Crisis Care Concordat.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
3
Include information held on deaths in psychiatric detention in all future annual reports.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
4
Test the new mental-health inspection methodology through Wave 1 inspections and use learning to strengthen regulatory responses.
Stated byCare Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2014.
5
Publish a specialised mental-health inspection and regulatory approach incorporating integrated regulation, Mental Health Act monitoring and specialist inspection arrangements.
Stated byCare Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
6
Work with partners to develop a method for using death information to improve intelligence, shared learning and preventative action.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 March 2014.
7
Operate a rolling programme of detailed internal compliance inspections through a dedicated team of experienced compliance inspectors.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
8
Improve registration and monitoring of patients attending ward therapy groups.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
9
Introduce weekday morning flash meetings involving ward, medical and management representatives to review activity and plan the next 24 hours.
Stated byPriory GroupStated completedThe respondent said that this action was complete when they made their response on 5 March 2014.
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Information checked against the published report and official responses