Jonathan Hamer

“There were communication difficulties experienced by [the deceased]'s family and his supported housing with the community mental health trust responsible for his ongoing healthcare during the early part of 2024. Telephone calls and text messages were unanswered and there was no communication to confirm that in fact the care co-ordinator had a period of annual leave followed by an unplanned period of sick leave. It was unclear at inquest if service users and their support network had been provided with”

“[the deceased]'s case was not "zoned" that is, given a priority coding on the case management system. Therefore, there was no expected period for case review or regularity of expected contact. The multi-disciplinary meetings and supervision meetings when [the deceased]'s case was discussed failed to recognise and address this issue. Appropriate zoning and regular reviews are a fundamental part of mental health care and should be embedded and prioritised as part of each patient's care planning”