Poor communications between agencies and/or staff
Non-observation of protocols or policies (or a lack of protocols or policy)
Lack of appropriate care or continuity of care
Poor communications with the patient or his or her family
Insufficient risk assessment
Staff shortages or a lack of funding, available facility or available beds
Delays in providing the required treatment
Insufficient training or recommended that training is needed
Failure to refer for ongoing mental health care
Family/friend/GP fears ignored
Failure to provide medication/inappropriate medication
Patient was without care plan or care plan was inadequate
Issues around confidentiality