Christopher Higgins

1. 1. staff unawareness of observation requirements

   “It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation”

2. 2. inadequate escort policy for patient transfer

   “The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for.instance the Police. In particular, Mr [name redacted] who had been acting in an unpredictable and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him”

3. 3. unassessed disabled ramp safety

   “The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete'floor, had not been risk assessed prior to taking Mr [name redacted] outside for a cigarette”

4. 4. lack of protocol for detained patient assessment

   “There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E, as a result of which Mr [name redacted], was required to wait over 2 hours in a busy, public area, having already self-harmed and shown signs of paranoia”

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