A review of David Stevens' death finds multiple failures, some of which were known about before.
Known failures at a mental health trust revealed in four deaths may have played a part in a man's suicide months later, an inquest has heard.
While he had assessments over the phone and in person, his first proper therapy session was not scheduled until 21 June. He repeatedly expressed concerns over his medication, but no review was arranged and he was instead told to speak to his GP The crisis team was in special measures and under pressure, with staff not having time to update the records fullyNo rationale was provided for why he was originally assessed to not be in psychosisHe repeatedly said he was struggling to sleep but was not offered sleep hygiene or relaxation techniques which might have helped himMs Lewendon said had he survived until his appointment on 21 June, he would have waited 21 weeks since being referred for "active" treatment to begin.
Ms Lewendon also said no-one took a "helicopter view" of his multiple calls to the trust's teams, which should have led to his care plan and risk being re-assessed.The coroner also heard a thematic review was carried out by the trust in November 2021, seven months before Mr Stevens' death, following the deaths of four patients who had contact with the crisis team.
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