Amanda Richardson

“The evidence taken at the inquest revealed that Ms [name redacted] had been prescribed euameme for a period of about six months at double the stipulated maximum dose”

“It was admitted that the prescription oa the rate of ng/day was double the mg/day stipulated maximum (without additional monitoring being undertaken) and was made in error”

“On 19.4.23, Ms [name redacted] was permitted unescorted leave in the community under S.17 MHA 1983. She did not return. She did, however, voluntarily reappear at the hospital the following day, albeit under the influence of illicit drugs and alcohol”

“Despite the seriousness of the 19.4.23 incident, no searches were carried out in her room or the hospital grounds in the period following her return”

“The inquest was unable to establish how or when Ms [name redacted] obtained illicit illegal drugs”

“an Internal Serious Incident Review has taken place”