Caroline Harris

“important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome”

“Information relating to Ms [name redacted]' decision to stop taking her medication, as well as concerns raised by Thames Valley Police about a decline in her mental health, was not passed on to the Adult Mental Health Team”

“Consequently, they were unable to supervise her adequately”

“AMHT's view was that such a report met the criteria for being shared with them, and with their knowledge of [the deceased]'s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act”

“The report stated that it was, 'Shared in the interests of safeguarding as may be having relapse'”