Natalia Cestaro

“risk assessments may focus primarily on specific previously ingested items, rather than undertaking a sufficiently proactive assessment of a wider range of swallowable items within the inpatient environment”

“limited detail demonstrating how liaison, shared responsibility, and specialist input are consistently achieved in practice when a mental health inpatient is transferred to an acute hospital for physical healthcare”

“processes described as standard practice, including regular contact following transfer, may not be subject to routine auditing or assurance”