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10.47  Jury return for day, reminded of their instructions and sent out to continue deliberations .

Coroner is discussing the Prevention of Future Deaths report that he has the opportunity to write. More info here

Submissions now and later this morning the Coroner will announce whether he intends to produce a report .

10.48  We consider the immediate Prevention of Future Deaths issues as following,  [Counsel for LB’s family] outlines…..

1) Communication with families/carers and issues of consent and autonomy;

2) Training and guidance for staff on balance of dignity and safety;

3) Communication between staff inc problems with RiO and recording info; change in practice as result of transitioning to computer system. Previously responsible clinicians would sign off paper care plans and risk assessments; disconnect now and lack doctors supervising plans;

4) Training: how effective can training be if staff can come to and still maintain its ok to leave LB in bath for 15 mins?  There is a gap between what the Medical Director at is saying shd be done and what is happening on the ground Given ‘s high reliance on agency staff and poor staff retention how do they ensure agency staff are adequately trained?

5) Handover periods – disconnect between staff thinking not enough time and management thinking there is and patients get lost in middle

6) Clinical Team Mtgs – named nurses only went CTM on one occasion, how can have patient centred care if ppl who know patient aren’t there?

7) Holistic care – clarity required around observations/checks and psychiatric/holistic obs; obs policy doesn’t require holistic approach

Concerns around ability to learn lessons outlined by

Consistent failure to disclose info in timely manner.  Documents served to the family days before inquest, found out during inquest about previous death on STATT

10.58  PB [to Coroner]: Very grave concerns that not all information that’s relevant has been disclosed to your inquest by .  We know that we and the Coroner have not seen the SIRI report from 2006; must be relevant to prevention of future deaths .  An enquiry into an Article 2 inquest must be thorough, you have not seen all the information because the 2006 report has not been found.  PFD reports are intended to influence practice…. it falls in yr jurisdiction to make it clear that failed to disclose.

11.07  Now of gives evidence. We won’t be tweeting it.

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