Stuart Berry

1. 1. failings in care coordination and discharge planning

   “A significant number of the causative failings identified in this case have previously informed PFDRs issued to EPUT and have claimed to have been addressed in responses to those PFDRs”

2. 2. failures in care coordination

   “Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy”

3. 3. failures in care planning

   “Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr [name redacted]'s Care Plan consistent with Trust policy”

4. 4. failures in risk assessment

   “Failures in Risk Assessments: specifically, failures to appropriately up- date and document matters relating to Mr [name redacted] risk assessment consistent with Trust policy”

5. 5. inadequate documentation

   “Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy”

6. 6. failure of joint working internally

   “Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals' Meeting”

7. 7. failure of joint working externally

   “Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration”

8. 8. failure in communication

   “Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased's Family to gather collateral information and to provide a carer's assessment and/or support to Mr [name redacted] family”

9. 9. inadequate national training

   “Evidence was given by a senior Prison Officer working for Prison Learning and Development at HMP Chelmsford responsible for providing Prison Officer [name redacted] Training (POELT) to new officers at HMP Chelmsford, regarding the training that would have been received by the officers involved in the opening and maintenance of Mr [name redacted] ACCT document”

10. 10. unaddressed ligature points in prison cells

    “A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate, in at least some cells on each wing, the most obvious of ligature points in the Victorian Prison estates' cells, namely the readily accessible fixed bars at the windows”

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