Tom sought help for depression, stating that he had suicidal thoughts. He was assessed by the MH team, but the assessment wasn't properly recorded; no discharge letter was sent to the GP, meaning that Tom didn't get the medication he needed.

"It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training. It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care."