MW: It was recognised and documented that Pathway House was not a safe environment, so what needed to be done, certainly after the bridge episode, there needed to be a clear multi-disciplinary multi-agency working of all those who knew Colette

MW: It was recognised and documented that Pathway House was not a safe environment, so what needed to be done, certainly after the bridge episode, there needed to be a clear multi-disciplinary multi-agency working of all those who knew Colette