Simon Reynolds

1. 1. lack of documented risk assessment at admission

   “there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit”

2. 2. missing admission record in Rio notes

   “the nurse in charge made no record on the computerised Rio notes in relation to the admission”

3. 3. inadequate staff guidance on observation and risk communication

   “consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff”

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