Roger Stevenson

“[the deceased], as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed”

“There was a need for recognition of service users with cyclical chronic mental ill health issues - in this case being that help [the deceased] received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions”

“That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm”

“KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department”

“KMPT needed to consider provision of long-acting injection type (depot) medication to ensure compliance, particularly where a service user may have to wait substantial periods of time for other services such as therapy”

“That mental health practitioners did not have means by which to engage with the families of service users, effectively recognising such families as an additional resource able to support mental health treatment by monitoring service users and encouraging them to engage with such treatment (and as an adjunct to that a way of noting that where consent has been given by a service user to disclose matters to family members this is clearly noted so that mental health staff are aware of it and can act”