Kieran Crimmins

1. 1. unrecorded actions

   “I was told that the Crisis Recovery and Home Treatment Team ("CRHT") use the Care Partner records, a whiteboard and a manual diary to enter the various information and action points and that it is at the Multidisciplinary Team meetings that the actions or steps are discussed and progressed. They are either crossed out, if completed, or moved to the next date until they have been actioned. It was highlighted that in this particular case two actions were not completed either prior to [the deceased]'s”

2. 2. inappropriate communication

   “The evidence I heard from one witness described how she was asked to contact [the deceased] by telephone and to advise him of the fact that a Multi-agency Referral Form ("MARF") was to be submitted. I considered this was an inappropriate means of communicating a significant procedure and which could potentially bear on his (or any other vulnerable person's) state of mind”

3. 3. no pathway back to mental health service

   “I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan.”

No published response was found on judiciary.uk.