Claire Lilley

“Individuals who are the subject of detainment under the Mental Health Act are risk assessed at numerous times. For those that are on Section 17 home leave, they are additionally assessed prior to leaving the ward on each occasion. In addition, risks are also reviewed on the regular multi-disciplinary ward rounds.”

“However, such assessments are not centralised in any one place - there is no central formulation. Reviews by any clinician would have to cover 3 or 4 different entries by way of example: the risk assessment page, the MDT notes, the psychology entries (although they, per se, do not enter risks assessments).”

“The Court's expert confirmed that such a centralisation/ formulation (supported by the Route Cause Analysis report), would assist in reviewing an individual's risk and allowing ward staff to see the wider input in one place.”

“Training has been implemented by the Trust to assist staff in formulating risk, a process that was in place at the time of [the deceased]'s death. However, there is no central repository/formulation of the outcomes of those assessments. Different teams continue to use different tools; there is no stand-alone document.”

“Consideration should therefore be given to the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of their own speciality.”