Philip Evans

“The Health Board conducted an investigation into [the deceased]'s death to include a review of his previous mental health care and treatment as well as Emergency Department (ED) care and treatment. This did not identify any concerns from an ED perspective (conducted by a Head of Nursing). The report had been reviewed and approved by the Director or Nursing for the Mental Health and Learning Division and the Integrated Health Council Director.”

“I am concerned that the quality, effectiveness and timeliness of the Health Board's investigations means that issues or concerns with care and treatment are not being identified either at all or quickly enough in order to put in place additional measures or learning to prevent deaths in similar circumstances.”

“I have issued several Reports pertaining to this very point over a long period and yet the same concerns remain.”