Isobel Griffin and Jane Clark

1. 1. uninformed leave granting

   “The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented.”

2. 2. delayed key worker allocation

   “Mrs [name redacted] was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th. 2. The risk assessment was not updated with the events of the 7th”

3. 3. clinician unaware of self‑harm attempts

   “Mrs [name redacted] responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3‐4 times tried to hang herself using a ligature.”

4. 4. inaccurate risk assessment documentation

   “A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances.”

5. 5. non‑ligature‑proof doors

   “The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk.”

No published response was found on judiciary.uk.