Sean Fegan

1. 1. lack of adequate assessment leading to denial of mental health treatment

   “Decision making surrounding the need for secondary mental health care - as set out above, a decision was taken in December 2019 that Mr [name redacted] did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect”

2. 2. delayed or denied mental health treatment causing overdose risk

   “Access to mental health treatment -Mr [name redacted] had complex mental health conditions and experienced very high levels of distress and anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust. Mr [name redacted] took an overdose due to his frustration at not being able to access mental health services which he needed”

3. 3. lack of integrated dual diagnosis services

   “Dual diagnosis - it was acknowledged that there was a 'gap' within the services in relation to dual diagnosis patients. There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems”

4. 4. failure to engage family in care planning

   “Liaison with family members - there was no evidence of proactive attempts to engage with family members, even when services withdrew. When a family member sought to share concerns, these were rebuffed”

5. 5. care plan overridden without proper assessment

   “Implementation of care plans - a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr [name redacted], on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr [name redacted] was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have 'agreed' that”

6. 6. misinterpretation of autistic communication leading to inadequate care

   “Autism awareness - I was concerned that Mr [name redacted] presentation acted as a barrier to a proper understanding of his mental health needs. In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather 'jumped' to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one occasion”

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