Discharge and safety netting

The discharge report for Gareth did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers. The information within the discharge report was not fit for purpose and did not provide for an accurate or full handover to new healthcare professionals.

Review of the medical notes

There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state.

Failure to update risk assessment

There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s presentation had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments.

Record Keeping

There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records.