Rebecca Marshall

“At inquest | was told that both Trusts involved: SLaM and KMPT had investigated the circumstances of Miss [name redacted] death independently”

“At a pre-inquest review hearing on 18 October 2018 | suggested that in light of the circumstances of the case it would be preferable for a joint report to be produced focussing on the apparent lack of interagency communication which had apparently led to Miss [name redacted] not being reviewed as required”

“Both reports identified a number of missed opportunities in Miss [name redacted] care, including steps to ensure joint ownership of her care when she became a student in London”

“what !| was told at inquest however, it avypeared that KMPT had not taken any steps to address the issues of obtaining collateral information from or sharing information with other Trusts involved in the care of one of their patients, particularly if they have moved, perrnanently or temporarily to / from KMPTs area”

“Miss [name redacted] formed part of what could be considered to be a particularly vulnerable group of individuais, namely a member of the student population suffering from mental health challenges whose continuity of care could not be guaranteed by good inter Trust communication”