fully accept that since this tragedy the Trust has instigated an internal review and is committed to a number of measures as a result of lessons learned from this tragedy a) An emergency referral by the general practitioner to the assessment team on the 4" of April 2013 was not followed up wilhin the normal time scale of four hours and it was two days before a telephone triage session took place and four before an assessment was undertaken by a mental health nurse: This raises the need to ensure that emergency referrals are dealt with within the appropriate time scale and (hat policies and procedures are in force to make sure that this happens b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too There was some lack of understanding revealed as to whether a referral to the assessment team or Ihe crisis resolution and home treatment team was appropriate This highlights the need for there to'be a clear underslanding about the roles of each team and the interface between them: c) On the 8h of April 2013, despite the fact that Mr Dunham was presenting as feeling suicidal and specifically that he had set up a noose in his fiat the previous night; it was not thought appropriate to refer him to the crisis team for appropriately robust intervention_ This raises Ihe issue of the basis upon which the risk of suicide or serious self harm is recognised and acted upon particularly where the person concerned has gone beyond vague suicidal ideation and moved towards contemplating some specific way of ending his life: d) A letter sent to Mr Dunham's general practitioner from the advice and assessment team was not drafted appropriately. This raises the issue of the need for specific guidance to be given about how such lelters should be drafted within a template structure. e) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care_ Specifically when a mental health nurse saw Mr Dunham on the 8"h of April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners_ It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014. NB. It is fully recognised that the Trust has commendably committed itself to learning lessons as & result of this tragedy_ However; the inadequacies revealed in what described at the inquest as the "fragmented and uncoordinated" approach to Mr Dunham's care clearly demonstrate the need for these issues to be addressed speedily and comprehensively in the interests of seeking to reduce the possibility of further fatalities taking days every