2nd

_ (1) In respect of the in-patient management: that there was no separate policy or guidance, other than a pictorial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm_ The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered, and this led to a lack of clarity and consistency: (2) With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope_ The item obstructing Christopher's ainway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle Laryngoscopes are not part of the standardised items on the unit, and are not included in the Resuscitation Council guidance for mental healthcare settings. It has been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However;, in view of the circumstances of Christopher's death, and the apparent pre valence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use_