Changes have been made to prevent future deaths, say bosses of a mental health ward in Sheffield where a man was found hanging.
Keith Dransfield, of Wincobank, died after being found hanging at The Longley Centre, which is within Northern General Hospital but is run by Sheffield Health and Social Care NHS Foundation Trust (SHSC).
His grieving widow told how she believed the 70-year-old accountant and grandfather-of-two would still be alive today had staff at the trust listened to his family’s concerns.
A coroner has now written to the trust calling for action to be taken to prevent future deaths in the wake of concerns identified during the inquest this summer.
Writing in a document known as a regulation 28 report, published this week, Coroner David Urpeth said: “During the course of the inquest the evidence revealed matters giving rise to concern.
“In my opinion there is a risk that future desks will occur unless action is taken.”
He wrote how Mr Dransfield was on an inappropriate observation regime, having been moved from 10-minute check-ups to less frequent ones, and no clear risk assessment was carried out for him.
He also said that staff on the ward did not routinely consult patients’ records and there was a lack of appropriate training.
The trust said a number of changes had already been made since Mr Dransfield, who attended the hospital having experienced suicidal thoughts, died on September 30 last year.
Clive Clarke, the trust’s deputy chief executive and executive director of operations, said it had already responded to Mr Urpeth detailing the actions it had taken, including changes to its policies on observations and record keeping.
“Regular formal audits of care records on all inpatient wards are now conducted, providing assurance that policies and procedures are being followed appropriately,” he said.
“These audits include a review of risk assessments and care plans for timeliness and quality. Other actions taken include the implementation of a programme of bespoke suicide prevention training for staff.
“The majority of these actions had already been taken following the conclusion of our own internal investigation into Mr Dransfield’s treatment and care and were shared with his family.
“I would like to reiterate our determination, as an organisation, that we offer a safer, more supportive service for everyone who uses our in-patient services following this extremely sad event.”