Rachel Morgan

1. 1. lack of medication review

   “am concerned that despite the fact that [the deceased] and her family made it clear to the staff at the Medlock Ward from the start of her admission that she wanted her medication to be reviewed as felt that her anti-depressant medication was not working, no steps were taken to begin the review process during the 4 days she was an inpatient before her death”

2. 2. inadequate risk assessment

   “am concerned that on 2 occasions matters came to the attention of the nursing staff that gave them cause for concern regarding [the deceased]'s risk of self- harm/ suicide and that neither of these incidents generated a full risk assessment to be conducted”

3. 3. lack of multidisciplinary review

   “am concerned that on 2 occasions that observations were considered and/or reviewed were conducted, they were not reviewed by a multi-disciplinary team as per Paragraph 5.4 of the GMWMHT Observation Policy 2012”

4. 4. policy ambiguity

   “am concerned that there is a lack of clarity around the different levels of observations contained within the GMWMHT Observation Policy 2012”

5. 5. over-reliance on inpatient status

   “am also concerned that staff at the Medlock Ward placed an over-reliance on the fact that [the deceased] was an inpatient as being a protective factor”

No published response was found on judiciary.uk.