Andrew Wells

1. 1. inadequate root cause analysis process

   “The Trust's Internal Root Cause Analysis investigation reviewed the decision making of the clinicians including the role of the treating consultant psychiatrist, the unit's Responsible Clinician. However, on one on the investigation team was a psychiatrist, or of a similar status to the Responsible Clinician. The RCA report agreed with the Responsible Clinician that the decision making around Mr [name redacted]' informal status and observation levels was appropriate. The draft RCA report went through a g”

2. 2. misapplication of Mental Health Act powers

   “The expert witness also stated the Mental Health Act was not applied appropriately. Namely, whilst Mr [name redacted] was technically an informal patient, the clinicians recognised that he would be detained if he tried to leave i.e. he was 'de-facto' detained without the additional resources and safeguards applicable to a detained patient being put in place. The expert witness said 'de-facto' detention was contrary to the Code of Practice to the Mental Health Act and Mr [name redacted] should have been detained.”

No published response was found on judiciary.uk.