Darren King

1. 1. lack of effective follow up action for disengaged high-risk patients with learning disabilities

   “The lack of effective follow up action when a patient with learning disabilities disengages, especially when they are a high-risk patient (such as [the deceased])”

2. 2. absence of clear escalation process for identified risks

   “The lack of a clear escalation process when an increased risk is identified and this risk cannot be easily addressed (as it was in [the deceased]'s case).”

3. 3. lack of structured medication review in care plan

   “The lack of a structured medication review as part of the overall Care Plan Approach so that staff from all agencies involved are aware of the importance of medication compliance and understand the referral/escalation routes should they have a concern”

No published response was found on judiciary.uk.