The inquest found that inadequate steps were taken by staff after an earlier altercation between the victim and the attacker, showing a failure to take decisive action that significantly contributed to the victim's death.
The jury highlighted issues of inadequate emergency training for staff, insufficient staff-to-patient ratio, and total failings that allowed the attacker to abscond, leading to chaos and panic during the incident.
The coroner issued a warning to hospital bosses about the risk of repeated failings, emphasizing the lack of real or simulated emergency training for staff members which resulted in a chaotic response to the tragic event.
#nhs-mental-health-hospital #staff-training #patient-altercation-handling #staff-to-patient-ratio #inquest-findings
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