Date of report: 18 February 2020

Ref: 2020-0031

Deceased name: Wayne Millett

Coroners name: Christopher Morris

Coroners Area: Manchester South

Category: Alcohol, Drug and medication related deaths; Hospital death (Clinical procedures and medical management) related deaths; mental health related deaths

This report is being sent to: The Priory Group

  1. The Priory’s own investigation lacked critical analysis of the care and treatment the patient received.  It failed to conder care against the care plan which was central in this case.
  2. When considered with the fact the group’s Director of Risk Management had input into the investigation and the Peripatetic Director of Clinical Services was unable to describe overarching quality assurance process when giving evidence raises concerns about the group’s ability to learn from serious clinical incidents.
  3. Divergent evidence was given by staff and Peripatetic Director of Clinical Services regarding adherence to care plans and this suggests that there is a need for audit of compliance with care plans.
  4. Despite a year elapsing since this death the organisation has yet to review the care plans of patients prescribed Clozapine to ensure these patients have a clear plan in place for potential side-effects giving  staff a clear plan for dealing with complications should they arises.  Of particular concern is the delay in this given that the Peripatetic Director of Clinical Services indicated this would be easy to implement.
Regulation 28: Report to prevent future deaths: Wayne Millett
Regulation 28: Report to prevent future deaths: Wayne Millett
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Regulation 28: Report to prevent future deaths: Wayne Millett – Courts and Tribunal Judiciary