and 19th _ 23ra _ self-key 10/h

(1) The Deceased's General Practitioner did not ensure the Deceased was monitored regularly, or at all, by a General Practitioner but preferred to rely upon the care she received from the CMHT.

(2) When the Deceased was seen at the GP surgery by a Staff Nurse on the 3rd 2012 (a) the Deceased's presentation on that occasion was such as to necessitate a review by a GP andlor referral to the Deceased's Consultant Psychiatrist, but no such review andlor referral was considered, and (b) due regard was not paid to the Deceased's computerised medical records prior to andlor in the course of consulting with the Deceased on that occasion as information provided by the Deceased to the said Staff Nurse was fundamentally incorrect which was apparent from earlier entries in the Deceased's said records (3) The Deceased was prescribed a significant quantity of medication on a monthly basis, such medication given in possession and unsupervised, without due consideration for the Deceased's medical history of self-harm and suicidal tendencies , which history was recorded on the Deceased's computerised medical records_ (4) Upon receipt of correspondence from the Deceased's Consultant Psychiatrist, due regard was not to the contents thereof and appropriate action was not taken.