Missed warnings in death of man in 20s

The report said details of Teo's discharge plan were "needed by all services involved" but they were not received by all of them.

There were also instances where details of his care were not shared between agencies, the report said.

It said communication between all parties was needed "to ensure effective co-ordination of care".

"This is particularly important in the higher risk period following discharge," it said.

"Since Teo's death, agencies involved in his care have already taken steps to address many of the learning points highlighted within this review," Mr Watts said.

He added the board would work with agencies to "ensure our most vulnerable receive greater protection".