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Patient death followed staff handover and record-keeping failures
Coroner finds mental health patient at high risk of suicide was allowed to leave a psychiatric unit in Springfield Hospital in London unescorted after nursing and medical staff repeatedly failed to read, understand and replicate plans related to safety off the ward or unit. His treatment plan said if he wanted to leave the hospital temporarily, he should be escorted by a member of staff or his wife. A spokesperson for South West London and St George’s Mental Health NHS Trust, which runs the hospital, says it is ‘deeply sorry that the care we provided was not of the standard it should have been’. They say the trust is working through the coroner’s feedback and will respond in full to address each of the areas highlighted.
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