1. Mr Ladapo lived with his sister, who wanted very much to be involved with his care. However, I did not hear any evidence of engagement with her by C&I, either:

- generally, during his time with the early intervention service or the rehabilitation & recovery team; or
- when in April 2022 he was found to have ordered a bolt gun on the internet that was only intercepted because it was discovered by the delivery driver; or
- on transfer from the early intervention service to the rehabilitation & recovery team in June 2022.

Lack of engagement with families is a story that I have heard often in inquests, and was the subject of prevention of future deaths reports that I sent to you on:

- 04.03.21 regarding Grazyna Walczak; and
- 17.03.21 regarding Ben O’Hara; and to your predecessor on:

- 11.01.16 regarding Efstratios Voukelatos; and
- 29.04.15 regarding Finnulla Martin.

2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal.

This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission.