Janet Williams

1. 1. lack of recorded CPA

   “Ms [name redacted]' care plan approach (CPA) was not recorded on the computer system and so there were no automatic alerts generated when she was not seen for review at the appropriate times”

2. 2. unverified patient narrative

   “Ms [name redacted] told her care co-ordinator that she was no longer hearing voices, but her daughter raised concerns that this was not true”

3. 3. protocol breach

   “Ms [name redacted] was not reviewed in accordance with the protocol for a person on a CPA”

4. 4. delayed review

   “A meeting was then scheduled three months' away, for 9 August 2016, despite the need for medical review and the lack of any alternative arrangement in the meantime”

5. 5. lack of coordination

   “Between 11 October 2016 when Ms [name redacted] was discharged by the home treatment team, to 21 February 2017 when she saw her general practitioner and her care co-ordinator together, Ms [name redacted]' care co-ordinator did not meet with her”

6. 6. no psychiatric review

   “Between 11 October 2016 when Ms [name redacted] was discharged by the home treatment team, and her death on 8 March 2017, Ms [name redacted]' care co-ordinator did not arrange for a medical review by the psychiatrist”

No published response was found on judiciary.uk.