a lack of appreciation on the part of nursing staff of the significance of • detention pursuant to the Mental Health Act; a failure by the nursing staff to translate Dr. Kent’s request for close • supervision into action; failure to exercise an appropriate degree of supervision over a detained, • psychotic patient; failures on several occasions to make any, or any adequate, entries in the • casenotes of events relevant to Mrs. Sanders’ treatment; a failure to act with a sufficient degree of urgency to Mrs. Sanders’ • absence on 3 September 1997. Key Words: death in custody; psychiatric illness; suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of April, 2000. ……………………………..……… Coroner Inq.No.2/2000
• a lack of appreciation on the part of nursing staff of the significance of detention pursuant to the Mental Health Act; • a failure by the nursing staff to translate Dr. Kent’s request for close supervision into action; • failure to exercise an appropriate degree of supervision over a detained, psychotic patient; • failures on several occasions to make any, or any adequate, entries in the casenotes of events relevant to Mrs. Sanders’ treatment; • a failure to act with a sufficient degree of urgency to Mrs. Sanders’ absence on 3 September 1997. Key Words: death in custody; psychiatric illness; suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of April, 2000. ……………………………..……… Coroner Inq.No.2/2000