James Boylan

“Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed 1 to have as few ligature points as possible”

“Mr [name redacted] appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr [name redacted] only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients' property. The origin of the cord which Mr [name redacted] used is not clear. It may have been his own, but the policy of having these kept centrally so that patients”

“There were numerous events over the 7 days during which Mr [name redacted] was present on the ward for someone with an overall view to realise that his condition was escalating and that he might become a danger to himself, but because no one person had overall knowledge of all the facts, this was not recognised. It is suggested that communication be improved in any way in which the Trust thinks possible”

“Assessments should be more rigorously completed and disseminated so that staff are aware of their contents, because in relation to Mr [name redacted] this did not appear to have taken place so that an opportunity for communication of information was lost”