Blackpool’s coroner has raised concerns about record keeping at the mental health trust Lancashire Care following a man’s suicide.
Alan Wilson wrote to bosses at the trust, which runs The Harbour psychiatric unit in Marton, following the inquest into Adam Carter’s death.
The hearing “identified some discrepancies” in medical reports, Mr Wilson (above) said in a letter to the trust, with medics’ concern about Mr Carter’s suicidal behaviour not “clearly documented”.
He wrote: “The level of risk a patient poses as regards issues such as the risk of self-harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave, which was an important step in progressing towards that goal.
“However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital the basis for such decisions is clear from the records. If this does not happen then I have a concern future deaths may result.”
Mr Carter, 36, from Thornton Gate in Cleveleys, fell from the fifth floor of the Talbot Road multi-storey car park in Blackpool, on September 10 last year, after running off during an escorted trip from The Harbour, his inquest was told. He was being treated for bipolar affective disorder and ‘mania’, though that was believed to be under control. He had been on nine previous trips out without incident.
Lancashire Care said it was “very sorry and we will take the learning from the case to make changes”. It added: “We have taken the recommendations received from the coroner very seriously and as such we are now making improvements.”