Opportunities missed that could have helped Madi

PATRICK Cullen, of the Birmingham and Solihull Mental Health investigations team, launched a probe into Madi’s care following her death.

He concluded that there had been a “missed opportunity” by both the Community Mental Health Team and tertiary psychotherapy service.

“My findings was that the crisis care plan was not sufficient to support Madi through foreseeable and indeed predicted circumstances,” he said.

“She should have been provided with details in the event that she needed further support.

“But in view of the clearly escalated risk, the plan should have been revisited with some perhaps more assertive steps to contact Madi directly to have a discussion with her about recent developments in her circumstances and how they may affect her in context of her history.

“The risk assessment should have been updated so it was more contemporaneous. There should have been an urgent review by a consultant or medic or perhaps a referral for support.

“There should be a collaboration between whichever services involved to identify needs and risks and agree a plan of care which would include a crisis response and that response needs to be individualised to that person.”

Stephen Harrison – Madi’s stepfather for ten years – said: “We very much hope that the service now takes that opportunity and works better in the future.

“It potentially could have made a difference. Sadly, we will never know.”