Gillian O'Keefe

“the decision to discharge Mrs O'Keeffe 'for non-engagement from the local Mental Health NHS Foundation Trust care in January 2017 appeared illogical when it was likely, having regard to the facts, that she was in greatest need of their help: she was a service user of long standing, she had an acute deterioration in her mental state in March 2016, that there had been concerns raised by her family in October 2016 and that no professionals had been able to make visual contact with her since October”

“There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge nor attempt to ensure that there was a seamless transition to the GP surgery”

“Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up GP concerns or referrals particularly where there was likely to be a degree of urgency”

“There appeared no easy or appropriate way that the family were able to share information and their concerns about Mrs O'Keeffe's mental health with the professional team”