Before setting out my concerns, it is only right that that I acknowledge that the Trust has undertaken some work to address risks it identified as a result of its own internal review processes.

(1) There was a significant delay in David's referral to the Trust being triaged. When the triage did take place, I was told in evidence that David's referral was not triaged well, which had numerous implications for David's treatment later on. I was told that the Trust now provides more support for staff triaging referrals; however, this did not provide sufficient reassurance that the risks have been addressed. I am also mindful of Prevention of Future Death report (2026-0023), written by me on 12 January 2026, which contained a similar concern about the process for triaging referrals (albeit in relation to a different team within the Trust). This indicates that this may not be a localised, team specific, issue in terms of the triaging of referrals.

(2) David's Dialog+ assessment (an assessment tool, which includes questions to assess risk) was not undertaken by a clinician. I was told in evidence that, given the complexities of David's case, his Dialog+ assessment 'would have benefitted' from assessment by a clinician and that he should have been seen by a qualified clinician at that appointment. I heard evidence that the Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it. However, that plan did not include referral to be seen and assessed by a qualified clinician, whereas the evidence I heard was that there was an expectation that David should have been referred to a qualified clinician. While I heard and accepted the evidence that a patient in a similar situation to David would now be able to access the MHT+ team directly, the issue here is one of potential training concerns where non-clinical decision makers are potentially over-confident or may not fully understand the nature and effect of the decisions they are required to make. I was not reassured that this matter has been addressed.

(3) It was accepted in evidence that there was a delay in David being seen by a qualified clinician. It was further accepted that there were numerous 'missed opportunities' for David to be referred to, or seen / spoken to by, a qualified clinician. Again, I accept that a similar patient now, would be able to access the MHT+ team directly. However, the concern remains that there is potentially a wider training issue that could lead to continued 'missed opportunity' exposing future patients to continued risks.