Richard Jones

1. 1. lack of appropriate mental health assessment and follow-up

   “During the course of the Inquest | had cause to hear evidence from a number of witnesses involved in the care of [the deceased], a serving member of the Armed Forces, when he complained of auditory hallucinations, persecutory delusions, low mood, disrupted sleep and poor concentration.”

2. 2. absence of systematic review of referral and care pathways

   “can make a Regulation 28 report if he or she has concerns with a view to the prevention of future deaths”

3. 3. inadequate risk assessment documentation

   “a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”

4. 4. poor inter-agency information sharing

   “b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”

5. 5. unclear accountability for patient care

   “c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.”

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