Mark Kinzley

“I have doubts that the location of Mr [name redacted] care was appropriate. Mr [name redacted] was a socially isolated adult suffering from a profound neurological disorder and mental illness.”

“No formal assessment of Mr [name redacted] capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests.”

“During the same period, Mr [name redacted] was not referred for a mental health assessment despite, His history of mental illness. His history of deliberate self-harm. His history of accidental self-harm when agitated. His deteriorating mental state during the month prior to his death.”