Rohan Singh

“[the deceased] died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, [the deceased] had been subject to a personal search by police officers when the bracelet was seized. During [the deceased]'s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband.”

“Mr [name redacted] was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.”

“Mr [name redacted] was subject to rapid tranquilisation, following administration of this medication, staff failed to follow the Trust's monitoring process or complete relevant documentation. The failure to monitor [the deceased] was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.”