David Ireland

“Contact was made by Mr [name redacted] friend on the day of his death with the crisis team. Mr [name redacted] also spoke with them during the same telephone contact call. No advice was given that Mr [name redacted] could present at the emergency department should concerns continue about his mental health crisis. : Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr [name redacted] was not able to make any such decision and”