Keith Nottle

“Evidence was heard regarding the operation of a triage for patients who may be experiencing a mental health crisis. A practice had developed of bypassing specialist mental health assessment by means of telephone workers making their own judgments about the level of risk a person presents to themselves and others, and a judgment about whether or not they require urgent mental health assessment and / or treatment, based on a very limited criteria. This had the result of only a very small”

“lack of involvement of a care co-ordinator at the Trust, given that a variety of agencies and persons were involved in seeking to assist and treat Mr [name redacted]”

“lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr [name redacted] and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service”