JS: I think the difficulties came with when she was on the ward and this related to the care planning difficulties and the need to have made those care plans about what to do if she self-harmed. That management of self-harm should have been tighter.

JS: I think the difficulties came with when she was on the ward and this related to the care planning difficulties and the need to have made those care plans about what to do if she self-harmed. That management of self-harm should have been tighter.