Jean Pike

“[the deceased] was discharged from Ward F of Neath Port Talbot Hospital on two occasions shortly before her death by a consultant psychiatrist and that prior to the decision to discharge on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for [the deceased] in the community about [the deceased]'s mental health and the risks she posed to herself in the community”

“care co-ordinators are rarely if ever consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge a patient/person under secondary mental health care”

“there is evidence of regular and effective communication between support staff, community staff and hospital staff”