Sam Spooner

“There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr [name redacted] did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr [name redacted]”

“There was an excessive and unreasonable reliance placed upon Mr [name redacted] family by health care providers to keep him safe when those providers knew that Mr [name redacted] family were not in a position to do so”