Samuel Gomm

“The assessment of [name redacted]'s risk of self-harm was recorded by his care-co- ordinator in a Wales Applied Risk Research Network (WARRN) assessment tool in March 2019. This form of assessment was adopted by the Integrated Mental Health Services (Powys County Council & Powys Teaching Health Board) in Powys. I also received evidence that it is used throughout Wales by similar services”

“the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how [name redacted]'s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user.”

“WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker's, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities”