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1 The evidence taken at inquest revealed that Ms Richardson had been prescribed for a period of about six months at double the stipulated maximum dose. The pathologist expressed the view that the high" level oft ffound in her blood on [toxicology analysis could possibly account for her death onTS OwShe had also taken death was attributed to the toxicity of both the and in combination: 2 It was admitted that the prescription of at the rate of mglday was double the Imglday stipulated maximum (withoul addltional monitoring being undertaken) and was made in error _ This situation went unnoticed for some six months, until her death There was no effective system of review in the hospital in this period The pharmacist appears to have dispensed the drug without querying the high dose. The nurses who administered the drugs did not question it: The MDT meetings which took place did not check the dose or reflect upon its potential interaction with the several other medications prescribed. Overall, there was no effective resilience in the hospital's systems to safeguard against drugs bring prescribed or administered in error_
3. On 19.4.23_ Ms Richardson was permitted unescorted leave in the community under S.17 MHA 1983. She did not return: She did, however, voluntarily reappear at the hospital the following day , albeit under the influence of illicit drugs and alcohol: Evidence was given that nurses reported having searched Ms Richardson on her return, but no adequate written record was made to confirm the nature or duration of the search, nor by whom it was conducted, in breach of hospital policies Ms Richardson died some 9 days later. Despite the seriousness of the 19.4.23 incident; no searches were carried out in her room or the hospital grounds in the period following her return: The toxicology and pathological evidence indicated that she had taken heroin shortly before her death_ Her room was not searched even after her death, as assumptions were wrongly made that her death was due to a cardiac event;
5. Some time after hear death, Ms Richardson's clothing and belongings were returned to an aunt: She searched through them and found various plastic "wraps" which were taken to the police and subsequently tested and confirmed as containing and The inference is that these were present in her bedroom at the time 0f her deain
6. The inquest was unable to establish how or when Ms Richardson obtained illicit illegal drugs_ Concerns were expressed as to the adequacy of the security arrangements in this lOw secure mental health hospital as at April 2023. 7 . In fairness to the hospital, it should be acknowledged that an Internal Serious Incident Review has taken place. Evidence was taken from the Group Deputy Chief Executive in relation to the [overhaul of security systems, pharmacy review procedures, staff training and record keeping which has taken place since Ms Richardson's death.