Karl Cassimjee

Brief circumstances of matters of concern

1. During the Inquest, evidence was heard that:

. AMental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);

. The assessment completed by the Specialist Registrar was entered on the “Amigos” system in the incorrect format with no supporting entry form from the second section 12 approved Mental Health Practitioner;

. The assessment, as recorded by the Registrar was accepted to be sub-optimal;

. The record of the risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, Clear evidence that the deceased received advice as to what measures he could take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.

. Itis unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of physically taking the deceased back to his home) about contact with the MHHT or what action to be taken in the event of a deterioration in the interim;

A Mental Health Nurse had recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusional paranoid beliefs that do not seem to have been fully, adequately or properly evaluated by the Speciality Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not seen fit to recommend Mental Health Act detention — there being no means within the operational procedures in place for the nurses concerns to be taken into account;

. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified: a. The need for the Community Mental Health Team operational procedure to be revised; b. The need for a revised Multi Disciplinary Team agenda approach to attach and apply in such case; c. Areminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process;

However, the evidence received at Inquest confirmed that: i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned; il. The specific learning of the instant case has not been considered, namely: a. Upon a discharge with MHHTT follow up — that the “home” address has been verified and confirmed as suitable as fit for purpose for a patient with the deceased’s presenting condition and needs; b. Where the police or other agency have become involved in the transfer of the patient from hospital discharge to “home” that there is adequate instruction to ensure that the “home” is appropriate and instruction as to what action to take if it is not, or in the event of a deterioration in the condition of the patient;