Samuel Pearson

“Whilst there was good multi-agency working before Mr [name redacted] moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants.”

“referral was made by Mr [name redacted] GP 1 to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations.”

“plans were at a very early stage by the date of the inquest”