Peter Farebrother

1. 1. delayed transfer to Pine Ward

   “The delayed transfer to Pine Ward coming at the end of an evening shift prior to handover to the night shift.”

2. 2. failure to recognise constant watch status and lack of assessment

   “The failure by the receiving staff on Pine Ward a) during the remainder of the evening shift or b) at any time during the night shift to recognise that Mr [name redacted] had been on constant watch up to and including the transfer and that no assessment had taken place changing that status.”

3. 3. flawed assessment due to information breakdown

   “The assessment may well have resulted in a higher observation level and the basis on which it was made, consciously or subconsciously, may have been flawed by the earlier breakdown in information.”

4. 4. return of belt to patient leading to ligature use

   “The decision to return the belt to Mr [name redacted]. It was the same belt which a) Mr [name redacted] later hanged himself with and b) had resulted in Mr [name redacted] having been on constant observation at Holly Ward.”

5. 5. perception of ligature-free environment reducing risk awareness

   “The perception that Pine Ward may be ligature free may have lowered risk awareness. Staff may have felt that the need for higher observation and/or ligature avoidance had been reduced by the environmental safety features on Pine Ward itself, whereas the underlying risk remained.”

6. 6. sloping door not preventing hanging risk

   “The sloping door was intended to prevent or reduce the risk of hanging. Mr [name redacted] case has indicated that that is not so. No change has been made to the door and it is therefore possible that this means of ligature attachment could happen again.”

No published response was found on judiciary.uk.