Simon Moss

“The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient's own account could not be relied on. However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient's”

“the Manchester Triage System only provided the option of "suicidal ideation" or "self-harm" whereas there was evidence in the EPCR of planning and intent.”

“neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services. Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted.”

“none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means. The EPCR was accessible on systems available to the mental health nurse however.”