David Jukes

1. 1. insufficient information about arrest circumstances

   “The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. [name redacted] in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody. She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threated”

2. 2. breakdown in communication between services

   “The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. [name redacted] was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of the previous evening. It was not”

3. 3. failure to conduct mental health assessment in police custody

   “Despite not being informed by the BCPFT liaison and diversion nurse that Mr [name redacted] was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. [name redacted] in custody which it was stated”

4. 4. inadequate patient location tracking and follow-up

   “Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT's only recorded attempt to contact Mr. [name redacted] before the 9th October 2018 was a single call (which probably mistakenly went to his wife's phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication”

5. 5. failure to implement meeting action plans

   “It was planned that Mr. [name redacted] would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him. No explanation was provided in evidence nor was evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through”

6. 6. delayed risk assessment after patient re-engagement

   “On the 9th October 2018 a HTT clinician talked to Mr. [name redacted] on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr [name redacted] before the 12th October 2018. By this time there was reason to suspect Mr. [name redacted] was at risk of harm to self or others, was under the influence of”

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