The Department of Health has been criticised for the way it dealt with a mental health patient who ended up taking his own life
The inquest into the death of 35-year-old Onchan man Christopher Burrows has today heard evidence frrom an expert witness, Professor Patrick Carr.
An independent adjudicator who judges healthcare cases, he has written a report in which he says there were two missed opportunities to assess Mr Burrows under the Mental Health Act.
Professor Carr told the inquest this could have been done when Mr Burrows discharged himself from Grianagh Court on June 14 2011, and similarly at the lunchtime on the day of his death, June 16.
Neither of these opportunities were taken.
Professor Carr told the inquest he was particularly surprised an assessment was not considered at a clinical meeting about Mr Burrows on June 16, when it would have been a perfect opportunity.
He also said throughout June 2011, and earlier that year, there were shortcomings in the way information about Mr Burrows was documented.
There is no evidence of any risk management plan being drawn up at the time of his discharge on June 14, or after a visit from the Department of Health's Crisis Response Home Treatment Team, on June 16.
He said he would have expected these things to be done.
Professor Carr went on to say there were further issues with the formation of a care plan, which was not done properly throughout the time of Mr Burrows's care.