Andrew Largin

1. 1. lack of timely allocation to a team member

   “The ELFT serious incident (SI) review report identified that, although Mr [name redacted] was discharged to the Woodberry Wetlands neighbourhood rehabilitation team from the crisis (i.e. home treatment) team on 25 January 2022, the neighbourhood team did not allocate him to a team member until 3 February”

2. 2. failure to reassess and reopen case

   “the crisis team failed to reassess him or to re-open his case to the crisis team, but instead referred the community team to the neighbourhood team”

3. 3. lack of documented rationale for decision

   “the crisis team member who made the decision on 2 February simply to advise that Mr [name redacted] should be dealt with by the neighbourhood team failed to record any reasons for her decision”

4. 4. inadequate investigation of decision maker

   “the SI reviewing team had not even spoken to that crisis team member as part of their investigation, let alone fed back to her”

5. 5. absence of debrief documentation

   “there was a hot de-brief after Mr [name redacted] death. However, no notes were made of that and no entry was made on Mr [name redacted] medical record”

6. 6. misaligned understanding of response times

   “the crisis team and the neighbourhood team did not share an understanding of how quickly the neighbourhood team aims to make contact with patients, to assist in their decision making about the correct pathway for a patient”

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