Christopher Swain

“During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not enteriing a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when [the deceased] had last been seen alive. Whilst the Trust has indicated that all staff have received further training”