1. When Ms Page was transferred from Sapphire to Opal Ward, she disclosed that she had tried to hang herself whilst on Sapphire a few days before. Opal Ward staff members were shocked at this but, though they recorded the disclosure in the medical notes, they did not alert any staff member from Sapphire until after Ms Page’s death.

From the evidence given by the consultant psychiatrist on Opal Ward, there appeared to be a reluctance to draw attention to this information, because of the perception that it carried with it a criticism of the staff on Sapphire.

However, it was important that staff on Sapphire were told, both from the point of view of Ms Page herself, and because this was a valuable piece of learning for them that could affect how they cared for other patients. The worry about perceived blame should not have prevented prompt discussion.

There were other learning points discussed during the inquest, such as the necessity to search the laundry room as well as bedroom of a patient feared to be at risk of self harm; the potential for wardrobe doors to act as a ligature point and the desirability of sharing that learning nationally; and the training issues around use of alarms, ligatures, general patient safety and resuscitation techniques. However, evidence was given that steps have already been taken by the trust to act upon these and so I do not need to comment on them further.