Angela Brealey

“At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes”

“During the period that [the deceased] was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved. Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals may have been preferable. Is this something that the Trust needs to look at?”

“Generally the serious incident review process is a very helpful one. In this particular case however a number of concerns about [the deceased]'s treatment were not picked up by the review. Is pressure on those carrying out this process reducing the effectiveness of the reports?”