LB's inquest

The inquest is closed.

Thanks offered by @paulebowen to members of the jury and the Coroner and Coroner's officer @LBInquest

Coroner offers his condolences to Connor's family, friends and supporters

Coroner considers late disclosure concerning and will be writing to @Southern_NHSFT to seek an explanation; shd have been shared months ago

Coroner will continue to make enquiries into 2006 death of patient on STATT, may yet re-open that inquest; bears looking at in this context

Coroner: We've heard there is formal training at the Trust around communicating with families

Coroner understands there have been changes to observation sheets

Coroner is encouraged that there's a process of signing off and validating CTMs now

Coroner: STATT is closed

Coroner: Focus also required on staff to be trained in how to use Rio and where to put relevant information

We've heard toolkit is very good but need information to be accessible

Coroner: 2nd focus Rio and epilepsy risk and training; there's no designated place for relevant risk details

We've heard @CareQualityComm are not keen on full ban of bathing and Coroner does not recommend. Will copy report to CQC for their comments.

Clear guidelines from @Southern_NHSFT are required and clarity around what is meant in practice in relation to observations

Coroner will focus particularly on inpatient obs re bathing and epilepsy, doesn't share @Southern_NHSFT confidence around sight/sounds obs

First issue involves observations @Southern_NHSFT significant confusion amongst staff

Prevention of Future Death report to @Southern_NHSFT will cover two areas

Coroner will make a report under Regulation 28 on the prevention of future deaths #JusticeforLB

Coroner: Only 1-2% of inquests have juries and thanks the jury for their service

Jury now asked to each sign the record of inquest @LBinquest #JusticeforLB