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recurance

Outdated care plan and risk assessment

Closely relatedConfidence 0.78 · moderate2 reports · 2020–2021 One-page brief (print or PDF)

Ministry of Defence received 2 coroners' reports about this hazard between 19 Nov 2020 and 6 Dec 2021.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.

2
reports
2
different coroners
2020–2021
years
0.78
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Paul Hills↗

    19 Nov 2020 · Sonia Hayes · North East Kent

    “Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
    Original on judiciary.uk ↗

    Ministry of Defence responded, stating 2 specific actions.Response (PDF) ↗

    “We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”

    Stated timescale: April 2021

    “all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”
  2. 1 year 1 month later

    Raised again · 1st time

    Alexander Tostevin↗

    6 Dec 2021 · Brendan Allen · Dorset

    Closely relatedConfidence 0.78 · moderatea different coroner
    “There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
    Original on judiciary.uk ↗

    Repeated from the earlier report:riskassessmentcareplan

    Ministry of Defence responded, stating 1 specific action.Response (PDF) ↗

    “case. I will address each area in turn. Disclosure of information between DCMH and the Chain of Command. DCMH operates as an independent organisation, which sits within Defence Primary Healthcare (DPHC), a Tri-Service organisation in UK Strategic Command. Although military DCMH staff2 are drawn from the medical services of the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of all three Service chains of command. Mental health services play a vital Occupational Health role in”
  3. All reports to Ministry of Defence

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error