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1) The electronic record system is not the same across all mental health teams (Single Point of Access, Crisis Team Mindsmatter) meaning that not all relevant records were available at each point f assessment of Mr McDermott Mindsmatter use 'IAPTS' and the other teams use 'ECR Blue as opposed to there one record system for all to use and to ensure mental health records are in one place. Although Igave evidence that Mindsmatter now has access to ECR Blue ad the other teams have access to IAPTS, his evidence was that the system remains "clunky:" His evidence was that a new electronic system has been commissioned, but he did not know whether it was one system for all teams to have access to andlor whether the problems highlighted in this case would remain: In addition, the system is not due to be implemented for a further 18 months. He agreed that having one electronic system used by all teams would be of benefit;
2) In addition to the problems highlighted above of not having all records on one system, there was evidence of poor use of the records that were available resulting in liaison nurses who were assessing Mr McDermott having an incomplete picture: a) During the GP's telephone call to pat the Single Point of Access team on 16 March 2015, did not check the full records to learn the background of Mr McDermotts recent admission following an overdose; b) During her assessment of Mr McDermott on 27 March 2015, mental health liaison nurse; was only aware that Mr McDermott had taken an overdose of drugs and alcohol. She was unaware that Mr McDermott had been brought to Accident and Emergency whilst intoxicated having been located near the train station by police and having reported to them that he was having thoughts of jumping in front of a train, fact that was readily available In the records; Following his assessment of Mr McDermott on 6 April 2015, mental health Iiaison nurse; discharged Mr McDermott without a plan for referral into the crisis team for assessment: Part of his rationale for this was that Mr McDermott told him he had an appointment with the being

Mindsmatter on 9 April: This was incorrect (this date was in fact due to the be the first face-to-face appointment with the SPOA, which was subsequently cancelled) and demonstrates that either did not have access t0 or did not properly check relevant records;
3) There was evidence of poor training with regards to incomplete assessments and poor record keeping: In respect of the telephone call from the GP to at the SPQA on 16 March 2015, there is no evidence in the records to evidence that asked any questions regarding Mr McDermott's mental health, despite the fact that the GP was requesting referral into services for a mental health assessment. There is no evidence that followed the 'Storm' guidance (guidance that had not been disclosed at the inquest) to assess suicide risk factors or mental health issues. His evidence was that he would have asked the relevant questions but just did not document the responses, but found on the balance of probabilities that questions had not been asked;
4) Following on from the above, of particular concern was that line manager_ (the Access and Treatment Team Deputy Manager) said in evidence that negative answers to questions would not necessarily always be documented the independent expert; and all agreed that the records should always be a complete picture with recording of negative answers an essential part of that;
5) Mr McDermott's problems were repeatedly treated as substance misuse issues without any consideration or assessment of whether mental health issues might be the underlying cause of the substance misuse issues. Individuals assessing Mr McDermott repeatedly had their views clouded by substance misuse issues_ which prevented Mr McDermott from being referred into mental health services for assessment. Although the Trust's 'Team Incident Review' [TIR'] identified that a "more flexible approach" was required in relation to overlapping substance misuse and mental health issues there was no evidence at the inquest that trust policies or procedures have changed in this respect, nor any evidence of staff being trained to approach such cases differently;
6) Following telephone call made to the SPOA by Mr McDermott's mother on April 2015, In which she advised that she feared he was at risk of suicide and had written a suicide note, contact was made with Mr McDermott who confirmed he could keep himself safe s0 an appointment was made for him to have a face-to-face assessment at the SPOA on 9 April 2015. However_ this appointment was cancelled by the SPOA team on April because Mr McDermott had been assessed byl on 6 April following his attendance at Accident and Emergency. The SPOA considered that to assess him on 9 April would be duplication. The expert's view, with which agreed, was that this was a missed opportunity to have a face-to-face assessment of Mr McDermott in a non-crisis situation;
7) It was apparent that when patients are assessed and treated by other services, in this case Discover Drug and Alcohol Recovery Services provided by Greater Manchester West NHS Foundation Trust ['GMW'], LCFT do not have access to GMW records and vice versa. In a case such as where there is a significant overlap between mental health issues and substance misuse issues, it is of significant concern that services do not cannot share information to assist in their assessment processes to ensure that they are in possession of the the being this, full picture of an individual's presentation;
8) Although LCFT instigated 'Team Incident Review; the inquest found that it was incomplete in some important respects, most notably in that it_made no reference whatsoever to the telephone call from the GP to on 16 March 2015, an incident which found was the real trigger point at which Mr McDermott ought to have been referred into services. Further, the TIR fails to address, adequately or at all, a number of the concerns raised in this Regulation 28 report; Since the purpose of a TIR to investigate a death to identify areas of concern with a view to learning lessons, it is a substantial concern that the TIR was incomplete in several respects;
9) Although accepted that a number of issues had been highlighted by the inquest that he would be "feeding back" and "learning lessons from_ it is a significant concern that almost two years have elapsed since Mr McDermott's death and lessons have not yet been learned, especially since the Trust had been in possession of the expert's report for over 3 months prior to the inquest