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The coroner said there were serious failings by ward staff and management in recording, reporting and escalating these incidents, which led to increased risk for both patients and staff at the hospital. He had self-harmed on at least two occasions, was hearing voices and had said he no longer wanted to live, the inquest heard.But despite this, no safety plan was in put place to protect him, even though staff were aware he was a risk to himself.The RQIA failed to inspect the Grangewood unit after Davin Corrigan died, the inquest heard
During this two-year period, the doors were a factor in three serious incidents, including Mr Corrigan's death.
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