James Booth

“The inquest heard that the Priory had identified that the garden fence was a risk, in particular the section over the door, in about December 2019. There had been a number of escapes both over the fence and through it, in the months leading up to [the deceased]' escape. The number of escapes indicates that garden area was not safe. There was a plan to replace it but there were other priorities. More striking was that there is no national guidance for perimeter fencing and security for the outside areas”

“Two The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts. In particular, the form specifically designed for this with a section for completion - 'Incidents in last 7 days' which would have provided an information flow through was not completed. Whilst I heard evidence of steps taken to improve information exchange at a higher level than between”