Ellie Long

1. 1. incomplete electronic records and delayed disclosure

   “Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids”

2. 2. failure to maintain ongoing communication with GP

   “An initial full, updating letter was sent to [the deceased]'s GP. However no further updating information was sent. A letter was written providing updating information, but this was not sent. No further updating information was sent to the GP by telephone, letter or email.”

3. 3. inadequate communication with school

   “The evidence heard is that efforts were made to contact the school by telephone. However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school.”

4. 4. inadequate information sharing with external agencies

   “It is accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will”

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