Jason Lennon

1. 1. lack of monitoring of care pathway

   “CRT failed to effectively monitor whether Mr [name redacted] was on a care pathway appropriate to his needs”

2. 2. inadequate mental state assessment

   “CRT undertook a flawed review of Mr [name redacted] mental state on 29/7/19 which failed to assess that, [the deceased] was in relapse and was a risk of harm to himself and others”

3. 3. incomplete action plan

   “The Trust undertook a serious incident investigation report into the events leading to Mr [name redacted] death in November 2019 which made a series of recommendations for action”

4. 4. staff failings below regulatory standards

   “Accepted individual failings by staff within the CRT fall below standards set by their regulator”

No published response was found on judiciary.uk.