Changes ordered following patient’s jump from Leeds hospital window

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HOSPITAL bosses have been ordered to review procedures for psychiatric assessments after a patient jumped to her death from a Leeds ward.

The woman plunged from a window in an acute medical admissions ward at St James’s Hospital in 2011.

Following an inquest, a coroner has told Leeds Teaching Hospitals NHS Trust (LTHT) to look at the psychiatry support provided to in-patients.

Managers have 56 days to respond to the Regulation 28, which requires action to reduce the risk of harm.

LTHT chief executive Julian Hartley said: “It is extremely important that we implement this improvement and assure the coroner that we have taken action appropriately.”

The patient, who was in her 40s, jumped from the window of the ward in November 2011. She was pronounced dead at the scene.

An inquest was held by the Leeds and Wakefield Coroner last mont which led to the Regulation 28 being issued.

Yvette Oade, LTHT chief medical officer, told hospital directors that they were liaising with the city’s mental health trust.

“We are working with partners at Leeds and York Partnerships NHS Foundation Trust to ensure we have access to urgent liaison psychiatry,” she said.

The case is detailed in the latest report on serious incidents at Leeds hospitals – which also includes a patient being given the wrong lens in a cataract operation and part of a screw being discovered in another patient following a spinal operation.

Both are so-called ‘never events’ – which should never happen if procedures are followed.

A report to hospital directors said a tab on a screw used in a spinal rod was found inside a patient. The checking process has been revised.

Dr Oade said the other ‘never event’ happened when a cataract surgery operating list was changed at the last minute, and the wrong patient’s details were brought up on a computer, so the wrong sized lens was inserted. The mistake was identified before the end of the procedure and the right lens inserted instead.

“Processes were not followed and they have been reviewed,” Dr Oade added.

Other serious incidents included problems with equipment used in Downs Syndrome screening for pregnant women giving incorrect results, a patient admitted with MRSA who later died and another who was given a 24 hour dose of medication at once. They have recovered.

The number of serious incidents more than doubled last year, from 22 in 2012/13 to 56 in 2013/14. However hospital bosses said this was due to a new requirement to record the most severe pressure ulcers as serious incidents.