Delayed patient location despite police assistance

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.

• 2014 → 2019David Jukes4 years 9 months after Kirsty Pritchard · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight failures in the trust's systems to contact and locate patients who are at risk of self‑harm after discharge or release. The core issue is inadequate communication and contact procedures that delay identification of worsening risk.

  Kirsty Pritchard · 17 Oct 2014

  “there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm”

  Check it in the source

  David Jukes · 12 Jul 2019

  “Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT's only recorded attempt to contact Mr. [name redacted] before the 9th October 2018 was a single call”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust processes, including the function and service provided by CHTT, are currently under review as part of a wider mental health strategy review. This is taking place in order to modernise services, improve quality of care and access to services. This review will also ensure a seamless service across both the adult and older adult population. The plan is to implement agreed changes to the current system by April 2015.”

  Earlier report in the app · Later report in the app