In the circumstances it is my statutory to report to you_ During the Inquest; evidence was heard that: 1_ Staff were unaware of the situations where it was appropriate to breach patient confidentiality and notify family or friends, When concerns arose regarding patient safetylwelfare; Ward staff needed to have a greater understanding of how to prioritise new admissions and ensure better flow of patients through the ward Ward staff and ward doctors need to have a greater understanding of each other's roles and responsibilities in relation to managing patient risk and whose responsibility it is to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision rationale (documenting any changes in risk and capacity) . Doctors and ward staff involved in making decisions about self discharge should consider the circumstances of admission as well as current risks when making decisions around discharge: also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act; Section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. I request that you undertake a review to ensure staff receive appropriate training on the _issues identified above