Katherine Tyrer

“The ward layout did not lend itself to easy observation of patients. The Court's expert considered it 'wholly inadequate'. The jury felt that this contributed more than minimally to [name redacted]'s death. A number of rooms (including [name redacted]'s room, 23) were remote from the nursing station and largely out of sight unless visited for a specific purpose. Whilst I am aware that some changes have been made since 2018, I am concerned that the current layout continues to place vulnerable patients, who might”

“The argument with her husband was a trigger event for [name redacted]. She was seen briefly by some ward staff between her return to the ward at around 10:25 and 11:00, but left completely unattended between 11:00-12:00. The jury felt that there was a missed opportunity at this time to affect the outcome and that the assessment of the risk that [name redacted] posed to herself had been inadequate. The evidence indicated that ward staff (seemingly regardless of their level of experience and seniority) who attend”