1. There was a limited risk assessment and risk management plan documented for Gerard on ward B2 now Beech ward
2. There was an inadequate door board system for monitoring the return of patients after unescorted leave on ward B2. The same arrangements remain currently, despite the ward move to Beech ward on new premises
3. There was extremely limited family and carer involvement in Gerard’s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward
4. There was limited awareness of the ligature risk reduction pathway by staff on B2 now Beech ward