- A father rang the ward about a worrying social-media post from his daughter hours before she died, but staff did not record the call or act on it as they should have.
- The inquest highlighted poor communication and unclear risk triggers after the teenager’s recent, last-minute transfer and a planned reduction in observations.
- Regulators had already flagged safety risks at similar wards, and the hospital was still implementing fixes; the inquest into her death is ongoing.
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