Shropshire Deputy Coroner Heath Westerman recorded a conclusion of suicide at the inquest into the death of Jack Doran, 28, from Shrewsbury.
The two workers on duty were temporary, due to staff shortages, and the correct procedures were also not followed when it was realised he was missing – three hours after he was last seen. The coroner recounted how he had heard evidence from Alison Blofield, the consultant nurse and approved clinician in charge of Jack's care, that she would have approached his treatment differently if she had been told of the family's worries.
Delivering his conclusion, Mr Westerman detailed the failings at the centre that had contributed to Jack's death. "Fourth, staffing shortages on September 4 were filled by temporary bank staff, not familiar with the Redwoods Centre guidelines and policies on missing persons. Consequently the correct procedures were not followed – this involved a lack of escalation, search, reporting, ownership, leadership and accountability."
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Source: BBCShropshire - 🏆 86. / 53 Read more »