(1) I was told that the Crisis Recovery and Home Treatment Team ("CRHT") use the Care Partner records, a whiteboard and a manual diary to enter the various information and action points and that it is at the Multidisciplinary Team meetings that the actions or steps are discussed and progressed. They are either crossed out, if completed, or moved to the next date until they have been actioned. It was highlighted that in this particular case two actions were not completed either prior to Kieran’s discharge from the CRHT or shortly thereafter. In one of these, the entry had been crossed out, giving the impression that the matter had, in fact been dealt with when it had not. This indicated that there was an issue as to the monitoring and execution of such actions or steps. This anomaly whereby a significant step may have been overlooked remains a concern.

(2) The evidence I heard from one witness described how she was asked to contact Kieran by telephone and to advise him of the fact that a Multi-agency Referral Form (“MARF”) was to be submitted. I considered this was an inappropriate means of communicating a significant procedure and which could potentially bear on his (or any other vulnerable person's) state of mind. What was unclear is how the provision of this information and step to be taken will be approached in future.

(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Therapy Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies. My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy.