Stephen Thurm

“information regarding the risk of self-harm to [the deceased] was passed by his family to his treating clinicians and his care coordinator but this was not taken into account as [the deceased] denied a recent attempt to take his own life”

“there is no designated gap between service user appointments to allow care coordinators to write up their detailed notes contemporaneously”

“expressed they were both suffering with a severe effect on their mental health but their care needs as the main carers was not built in to any long term plan”