Nigel Harper

“On 4 July 2022 Mr. [name redacted] attended the Emergency Department at Gloucester Royal Hospital, and was seen by a nurse from the Mental Health Liaison team there, who recorded that he was very anxious and distressed, and voicing on going thoughts of suicide. The nurse felt that Mr. [name redacted] would benefit from a period of treatment under the care of the Home Treatment Team, and because Mr. [name redacted] was living in Worcestershire at the time, and because it was now in the early hours of the following day, he”

“If staff at HWHCT and GHCT do not understand how to make urgent mental health referrals or requests for urgent mental health assessments to each other, there remains a risk that other deaths may occur in similar circumstances in the future.”