Jeffrey Gash

“The Crisis Team nurse accepted in evidence that she had not been as forceful as she could and should have been to explore with the deceased his new symptoms, auditory hallucinations, hearing voices. This evidences a lack of training and understanding of the nature of and importance of an appropriate level of telephone assessment”

“No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision”

“Notwithstanding the fact that the deceased declined to attend the hospital for a face to face interview, insufficient weight was given to the reason therefore and whether domestic and other pressures were militating against him attending were not properly considered, if at all”

“Given that there was an insufficiency of enquiry into the deceased's state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had he not agreed to it voluntarily, then there ought to have been a compulsory assessment”

“The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a none in-person face to face is being undertaken”