1. The GP, understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status. The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal. In either event he should have been told who to call to get further assistance.
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments.
5. did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment.

6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this.