Alistair McDonald

_ Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be revlewed and redrafted The lack of a specific plan for referrals to other services which proved unsuccessful The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist: Ensuring a proper line of communication with the patient and the patient's family to ensure appropriate reviews If the patient's mental state deteriorates 5_ Obtaining detailed feedback services the patient IS referred to, to check on attendance and progress Recognising that some patients will only make partial disclosure of their true symptomology and history: Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have plan to review and deal with this 8_ Ensuring If there were any failed communications with patient or the family, to have plan to take specific action to deal with this. Action should be_taken In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action. Review the self-harm and sulcidal Ideation criteria Deal with the Issues raised in paragraphs 2-8 above_ Your response You are under a duty to respond to this report within 56 of the date of this report;, namely by 27 September 2019 I,the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action Otherwise you must explain why no action IS proposed Copies and publication have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of the deceased also under a duty to send the Chief Coroner a copy of your response. from the days am

The Chief Coroner may publish either or both In a complete or redacted or summary form He may send a copy of this report to any person who he believes may find It useful or of interest You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner N Meadows H.M: Senior Coroner Manchester City Area 29 July 2019