Hilary Guedalla

“The deceased was allowed to leave Gardener Ward ("the unit") which was part of a secure facility of the hospital, alone, when a clinical decision had been taken that they should not be allowed to leave the unit unaccompanied by staff, because they posed a serious risk of suicide.”

“The decision that the deceased should not be allowed unescorted leave was not communicated to all members of staff working in the unit such that the person who allowed the deceased to leave was unaware that the decision had been made”

“The relevant information gathered during the Ward Round on the 28th October 2021, which included the fact that the deceased had attempted to take their own life, the night before, was not adequately communicated to all staff on the unit”

“There was no proper system for identifying whether a service user should be permitted to leave the unit”

“The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment. Had that member of staff consulted the deceased's medical notes and records, the serious suicide risk which they posed would have been evident”