“are in relation to plastic bags/restricted items and, secondly, communications with family”

The coroner’s concerns

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are in relation to plastic bags/restricted items and, secondly, communications with family. | recognise that lessons have already been learnt following Liam’s death as set out in the Route Cause Analysis investigation and, specifically, in the action plan. Ms Klink gave further evidence about this. In relation to the first concern, about plastic bags as restricted items on the ward, the sad fact is that Liam was able to take his own life because he had access to plastic bags. They were Sainsbury’s bags. He attended Sainsbury's on Section 17 leave two days prior to his death. There was evidence that these bags were taken from nim on reiurn to the ward. {t could not be ascertained if this was correct and whether the bags which Liam used were bags which he obtained on the trip to Sainsbury's or whether the bags were obtained in some other way on the ward. | understand there have been improvements in the system in relation to plastic bags in particular. | appreciate however that the problem of plastic bags is not straight forward, particularly when one takes into account the fact that many patients are informal patients and are free to leave and return and that visitors may also bring plastic bags when visiting. | understand that there are clear warnings that plastic bags are restricted items at the entrance to the ward and that steps are taken to bring this to the attention of visitors. It would be helpful if | could be provided with further details about the steps that are in place. A related concern was the environmental searches that were intended, amongst other things, to check for plastic bags. | was shown what are referred to as daily environmental safety check lists which include plastic bags/bin liners on them. | had the impression from the evidence that, at the time, these checks were not being carried out as regularly as they should be. Indeed, | see that recommendation 2 on the RCA/Action Plan concerns standardising the frequency of environmental checks and monitoring of banned items across all in patient wards. It states that they should be carried out daily. It appears a policy is in place and a recommendation but it is not clear to me whether there is effective implementation. Consequently | request that this matter be reviewed and that | receive a response specifically about implementation. The second area of concern is about communication with family. Again, | realise that this is not a straightforward matter because there are issues of consent and it is also the case that some families are not supportive or united. However, in Liam’s case, it is clear that his family were very supportive and united in terms of Liam’s health and wellbeing. A concern at inquest from the evidence was that there was a need for improved communication in terms of information provided by family to staff and also from the staff (particularly concerning elevated risk) to family members. This will enable family to be more watchful. a in her evidence, referred to the “triangular approach” and recognised that there was more work to be done in this difficult area. She indicated that work was on going. It would be helpful if you could provide details about the current policy and practice concerning communications with family and if there is a programme in place, to improve it. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0347

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0