Inquest into the death of Sarah Higgins

Contributing factors

• failure to conduct observations in accordance with R15 observation regime
• nursing staff member providing assistance to another patient without delegating observation responsibilities
• lack of formal handover process when allocated nurse was called away
• inadequate staffing levels relative to patient numbers
• staff unfamiliarity with current observation policy requirements
• inconsistent handover process
• patient numbers exceeding ward capacity
• delay in referral to specialist psychiatric care by general practitioner

Coroner's recommendations

1. Observation policy should be amended to require that attending nurses keep patients on regular category observations within visual range whilst in general ward areas, to enable observation of general behaviour and interaction
2. Staffing formula should be strictly applied and followed insofar as possible; it is preferable to have too many staff rather than too few on shift
3. Observation policy should be amended to provide for regular observations to be handed over to another nurse in the event the responsible nurse is called away to an emergency
4. Ward managers should discourage any tendency to be optimistic about likely patient numbers when calculating staffing requirements
5. Address the situation where patient numbers exceed the Cowdy Ward's capacity by expansion of the ward, provision of a 'step down' facility, or other means
6. Consider amending the protocol concerning maintenance of the scene and notification of authorities to extend to attempted suicides, particularly where the victim is rendered unconscious and requires life-support