Inadequate transfer of suicide risk information

“As per the evidence of , Nightingale's is not a secure unit and a resident with a similar history to that of Ms [name redacted] would no longer be admitted to the Home. Should there be a concern in relation to a resident who was already admitted at the home, a system of 1:1 care would be implemented which would restrict access to any items. An urgent referral would therefore be arranged for assessment of the resident and the resident would be discharged to a more suitable placement/acute hospital.”

“4. The Local Authority have reviewed the case again after receipt of the Reg 28 Report and consider that the conclusion of Dr is correct, in that there was adequate assessment and management of risk of suicide and that the placement at Nightingale was appropriate. There may be some details to correct (e.g. layout of Overview document) but having had that opportunity the Local Authority does not feel there is specific action arising from the Report of its own review of actions and procedure that”

“BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated.”