Finding into death of CB

Contributing factors

• inadequate environmental safety - patient allowed to retain a ligature (scarf)
• failure to conduct formal systematic risk assessments at required intervals
• failure to complete consultant revised CRAAM form within 24 hours
• inadequate mental state examinations - last MSE on 26 October, none on 27 October
• insufficient nursing engagement with patient
• failure of nursing staff to recognise deterioration in mental state on day of death
• failure to escalate concerning changes in mental state to medical staff
• inadequate documentation of risk assessment rationale
• policy allowing low dependency unit patients to retain potentially dangerous items
• reliance on patient's verbal reassurances without considering contextual risk factors

Coroner's recommendations

1. Change NWMH policy to ensure patients in low dependency units cannot retain items capable of being used as ligatures, ensuring compliance with Chief Psychiatrist Guideline on criteria for searches to maintain safety in inpatient units
2. Adapt cupboards in patient rooms of BIPU to remove hanging points
3. Reassess current CRAAM guideline or policy regarding engagement level for patients rated low risk, with clear instructions for: frequency of formal documented mental state examinations across each shift; requirement for formally documented and notarised rationale explaining low risk determination; frequency, timing and recording of visual observation of patients
4. Provide focused and detailed training to nursing, allied health and medical staff of BIPU concerning static and dynamic risk factors for individuals with mental illness
5. Provide focused and detailed training to nursing, allied health and medical staff of BIPU about escalation and referral procedures to senior staff for changes in mental state and dynamic risk factors for suicide, including changes in perception and increased anxiety levels