Missing prior suicide attempt information

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2022 → 2023Paul Perrott1 year 5 months after Archi Johnson · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight that staff were not informed of a patient's previous self‑harm attempt, which hindered risk assessment and care planning. The earlier case concerns missing data in risk assessments; the later case concerns missing communication of a recent attempt description.

  Archi Johnson · 26 Jul 2022

  “The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”

  Check it in the source

  Paul Perrott · 11 Dec 2023

  “At least one member of staff was unaware that [the deceased] had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust has undertaken a Serious Incident Investigation following the death of [the deceased]; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.”

  Earlier report in the app · Later report in the app