Christopher Brennan

1. 1. lack of separate policy or guidance for self-harm risk assessment

   “In respect of the in-patient management: that there was no separate policy or guidance, other than a pictorial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm. The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered, and this led to a lack of clarity and consistency.”

2. 2. absence of laryngoscope in emergency equipment

   “the emergency equipment on the unit did not include a laryngoscope. The item obstructing [the deceased]'s airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when [the deceased] had swallowed a bottle top.”

No published response was found on judiciary.uk.