Carl Thompson

“I am concerned that the jury have found that the risk assessments and risk planning for [the deceased]'s s.17 leave in March 2023 was inadequate. This issue was not addressed in the Trusts' internal investigation conducted by [REDACTED] and I have not received any evidence that there have been reflections or changes following [the deceased]'s death on this issue to reassure me that there is not a continuing risk of future deaths.”

“I am concerned that the Trust's own internal review found that whilst [the deceased] was on leave from the 7th March, the clinical team were made aware of an increase in [the deceased]'s risk factors when contacted by his mother who outlined her concerns.”

“The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for [the deceased], including his use of non prescription medication and illicit substance misuse.”

“The Trust's own review concluded that the clinical team could have sought to understand these risk factors through direct contact with [the deceased].”

“own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask [the deceased] to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical support.”

“The review concluded that a risk to [the deceased]'s physical health was present especially in view of research and evidence for substance misusers starting to use again after periods of abstaining.”