(1) No entries were made by the RMN in the medical records specifically commenting upon the replies to questions in respect of self-harm or suicide, the only significant entries in the medical records on this subject being made by RGNs (2) No entries were made by the RMN after consultations/ACC T reviews with the deceased in the ACC T documentation resulting in no information being available to discipline officers managing Mr Peebles (3) No assessment by an RMN of a patient suffering obviously delusional symptoms on several occasions (4) No reading by the RMN of the ACC T documentation for collateral information necessary to assist in the diagnosis of a delusional disorder (5) RMN relying upon the summary of the ACC T documentation provided to her by the Senior Officer undertaking the ACC T review rather than assessing the documentation for herself to form a view of the information from a mental health perspective (6) RMN formed the view that Mr Peebles was not suffering from any mental health condition without reviewed the ACC T documentation, discipline documentation or undertaking any mental health assessment prior to informing the deceased of her decision. (7) on referral on 25 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place (8) RMN remains in the clinical post within the trust and does not appear to have undergone any supervision or retraining Coroner's Court; 2 Faraday Court; Faraday Drive; Fulwood, Preston; Lancashire, PRZ 9NB Tel 01772 703700 Fax 01772 7004422 having May

(9) the attendance at inquest by the healthcare manager without sufficient information to demonstrate that matters had improved, been resolved et cetera and having heard the suggestions to minimise future deaths by the expert consultant forensic psychiatrist who advises at a national level on matters of prisoner safety, effectively responded that that wasn't the way the Trust undertook its assessments (10) the lack of any Trust internal investigation into the death