Leslie Swindells

“the practitioner who saw Mr [name redacted] had very limited training in mental health and was employed in a role described as a mental health assistant practitioner.”

“he should never have had a review undertaken by someone with such a limited an understanding of mental health and that lack of understanding of mental health meant that the practitioner did not recognise the level of risk Mr [name redacted] posed”

“shortage of trained reception/admin staff meant that an agency worker was screening calls that day and had a limited understanding of how patients needed to be allocated”

“it was essential that all those in the practice understood the limitations of the role and that there was close supervision of the practitioner”

“it was envisaged by the practice that the GP on duty would have a supervisory role”