Alexander Holt

1. 1. minimising or concealing suicidal intent

   “The prospect that Mr [name redacted] was minimising or concealing the true extent of his suicidal intent should have been subject to a greater degree of challenge and his parent's fears in this regard should have carried more weight”

2. 2. failure to provide intended treatment

   “It was accepted at the inquest that there was a failure to provide the type of treatment originally intended”

3. 3. failure of SORT referral process

   “The referral process for SORT failed to materialise despite repeated concerns expressed”

4. 4. fragmented involvement of multiple parties

   “Mr [name redacted] parents described how too many people became involved in his care over a period preventing the necessary degree of continuity”

5. 5. lack of information about recent self-harm attempt

   “the staff 1 at Beaufort Road were not advised of Mr [name redacted] most recent attempt at self-harm (by overdose of his medication) and were thus unaware of the degree of risk when he returned to that address where support would have been available”

6. 6. inadequate risk assessment

   “It was accepted at the inquest that more could have been taken into account in risk assessing Mr [name redacted]”

Linked reports

No published response was found on judiciary.uk.