Stephen Adams

During [he course of irquest [he eviderce revealed mallers giving rise lj concern, In mY DFInIDn tnere is & risk that future deaths will cccur urless action is taken In the circumstances it i8 my statutory duty ta repor to You, The MATTERS OF CONCERN ara a5 follows_ (1) It emerged during the inquest that Rlsk Assesament dccument completed b} Ihe Mental Hcallh Liaison Team worker was naf complete in as much as tha box indicating tne a3s0ssment of quicide risk had nat bean completed The wilness indicated tat many workers do not complete Ihis box and the assessmant of fisk Is to be extrapolated Irori the acticns taken by lhe worker No where on the document I: Ine assessmentof nsk I0 be lound ACTION shouLD BE TAKEN The the berng the the

Immy OEinion acticn shouid be taken to prevent fulure dcaths an belleve power to take such action specifically to ensure that tho you have Ine and recorded on te assessment assessmentof nak Is properly papenyclk Your RESPONSE You a1e undcra duty to respond to this report within 56 days of the date of this namely by 'January ?016 |, the Coroner; may extend [he Feriog Tepon tour resBtnse must contain deta ls of ection taken or proposed ID be taken the timetable for actior. Otnerwise you Must explain settirg cui why no action i5 piopased,