A coroner has criticised a troubled psychological well being belief for failing a young person who took his personal life.
Nyall Brown, 19, from Cromer, died in Could 2018.
Norfolk coroner Jacqueline Lake stated she had considerations over workers not reviewing his care information earlier than appointments, which might have enabled extra correct assessments.
The Norfolk and Suffolk Basis Belief stated it was “introducing studying periods” specializing in preparation.
Ms Lake has written a Prevention of Future Deaths report back to the belief, asking it to take motion to guard others.
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“It is a matter which has been raised with the belief beforehand,” she stated.
“Workers are anticipated to learn earlier information regarding a service consumer, however this isn’t at all times occurring.”
She added: “Proof was heard that Mr Brown’s care information weren’t reviewed previous to his being seen, which might allow Mr Brown’s full historical past and dangers to be taken under consideration when assessing him.”
NSFT is the one psychological well being belief to have been put in particular measures, and in November was rated ‘insufficient’ for a 3rd time.
Mr Brown’s dad and mom Tracey and Mearl have been essential of the service, describing their dealings with the belief as “insufficient, poor and stunning”.
They first sought assist after their son tried to take his personal life in January, however at one level have been suggested to hunt personal medical assist.
Diane Hull, chief nurse at NSFT, stated an in depth evaluate had been performed into the occasions resulting in Mr Brown’s dying, and was being acted upon.
“This contains wanting on the interface between wellbeing and secondary psychological well being providers and our disaster groups, and strengthening scientific management,” she stated.
“As well as, we’re introducing studying periods which give attention to documentation, communication and the significance of preparation forward of appointments.”