The person who completed a risk assessment tool for Roomes was not qualified to do so, and did not refer him to a clinician when it should have done, according to the report.
Potter said there were concerns that non-clinical decision makers were “potentially overconfident” or did not fully understand the effect of their decisions.
The coroner said there were “numerous missed opportunities” for Roomes to be seen by a clinician.
A similar patient would now be able to access care directly, he wrote, but “the concern remains that there is potentially a wider training issue”.