Azra Hussain

“On the 4th May 2020 [the deceased]'s mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that [the deceased] had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to [the deceased] who denied making a ligature, [the deceased]'s neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that [the deceased] was not at”

“BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufacturers for 10”

“BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in- patient mental health units to place, or”