"There was a lack of information sharing and investigation in relation to the discharge planning for Mr Clayton. Contrary to the Trust’s policy he was not identified as a vulnerable patient. His family was not involved in the discharge planning. On a number of occasions, they raised their concerns as to his ability to live independently and were ignored. Staff were unaware of the discharge planning policy. The underlying cause for his presentation was not diagnosed. Discharge decisions were taken in a vacuum without understanding the recent history of frequent admissions, his diagnosis and without sufficient investigation of his home circumstances."