A case review carried out by Devon Safeguarding Children's Board has concluded that 15-year old George Werb was failed by The Priory hospital near Marchwood after a catalogue of errors led to the
A case review carried out by Devon Safeguarding Children's Board has concluded that 15-year old George Werb was failed by The Priory hospital near Marchwood after a catalogue of errors led to the hospital allowing George to go home for the weekend. Hours after George was released he tragically stepped in front of a train. George had been battling depression and was suffering from delusions that his medicine was damaging him. The case review concluded that:
- Inadequate records were taken by the consultant psychiatrist following consultations with George
- A risk assessment had been incorrectly written changing George's suicide risk from YES to NO the day before George died
- The management plan did not have any note of current or past risk of self-harm or suicide the day after George had made a suicide attempt
- A staff meeting had concluded that George posed "no current risk of suicide" two days before he died, contradicting a report given a few days before which noted that George had woken up in a low mood and had felt suicidal