The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment; and drug and alcohol dependency issues, who was potentially violent There was no policy in place to facilitate the general practitioners' referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death. This may have impacted on his ability to receive additional services and assistance with his homeless status. aged

Although this Trust have now put policies and facilities in place to treat patients presenting with a history of violence, it was clear evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon: While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care This is clearly a contravention of Equality legislation for those most vulnerable in society.