1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise.

2) A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on.

3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following:

– There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment

– “Discussions and assessments of risk should be clearly documented”

– “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions”

– There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”