"Danny took his own life, whilst suffering from a mental illness, and whilst receiving absolutely no care from the mental health services. Danny’s death was contributed to by cumulative failures, amounting to a gross failure, to provide mental health care to him."

The MH unit discharged Danny unsafely - no discharge info provided, no regard given to the environment he needed post-discharge, no s.117 aftercare sought or put in place.

The Community MH team failed to follow up on Danny's own statements; failed to communicate with the housing service or the GP about either Danny's needs or their own (lack of) actions; and failed to show any clinical curiosity about Danny's condition.