Gary Etherington

“The failure to contact at the Mental Health Act assessment in April”

“The failure to take and consider the history of before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to , about which there was an inadequate plan communicated to the GP”

“The fact that the deceased was under a restriction order not to contact his ex-wife was cited as a reason that no contact was made by the professionals conducting the MHA assessment”

“The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support”

“Neither failure was recognised or investigated by the Root Cause Analysis which was described as Level 2 Comprehensive and concluded that there were no problems in health care”