Stephen McDermott

1. 1. incomplete electronic health records

   “The electronic record system is not the same across all mental health teams (Single Point of Access, Crisis Team, Mindsmatter) meaning that not all relevant records were available at each point of assessment of Mr [name redacted] - Mindsmatter use 'IAPTS' and the other teams use 'ECR Blue' as opposed to there being one record system for all to use and to ensure mental health records are in one place. Although MR gave evidence that Mindsmatter now has access to ECR Blue and the other teams have access”

2. 2. failure to review complete medical records

   “During the GP's telephone call _- the Single Point of Access team on 16 March 2015, did not check the full records to learn the background of Mr [name redacted]'s recent admission following an overdose”

3. 3. incomplete situational awareness

   “During her assessment of Mr [name redacted] on 27 March 2015, | | mental health liaison nurse, was only aware that Mr [name redacted] had taken an overdose of drugs and alcohol. She was unaware that Mr [name redacted] had been brought to Accident and Emergency whilst intoxicated having been located near the train station by police and having reported to them that he was having thoughts of jumping in front of a train”

4. 4. premature discharge without referral

   “Following his assessment of Mr [name redacted] on 6 April 2015, fF mental health liaison nurse, discharged Mr [name redacted] without a plan for referral into the crisis team for assessment.”

5. 5. absence of suicide risk assessment documentation

   “there is no evidence in the records to evidence that asked any questions regarding Mr [name redacted]'s mental health, despite the fact that the GP was requesting referral into services for a mental health assessment. There is no evidence that [I followed the 'Storm' guidance (guidance that had not been disclosed at the”

6. 6. inadequate documentation of assessment outcomes

   “negative answers to questions would not necessarily always be documented. [NNN the independent expert, end I HEM all agreed that the records should always be a complete picture with recording of negative answers being an essential part of that;”

No published response was found on judiciary.uk.