Theo Brennan-Hulme

“Evidence was heard of a historic culture of bullying and harassment within the Crisis Resolution Home Treatment Team which has led to a loss of compassion in some instances with the view that some suicides are "inevitable" and some reluctance to recognise when cases should be referred to the Team. Work has been undertaken by the Trust to improve such cultural attitudes. However, it was recognised in evidence that there is "still a distance to go" and areas where the culture needs to change. It”

“Following an Assessment, a person is still discharged from the Community Team without any immediate "check" or discussion as to the correctness of this decision. It was heard that following [the deceased]'s death immediate discharge from the Community Team following assessment is relatively rare. In these circumstances, such a discussion would not place an onerous burden on the Team and would enable a review of the discharging decision to be undertaken to ensure it is the correct decision.”