Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Freeda Glausiusz · 20 Oct 2021 · Mary Hassell, Inner North London
“I never received a copy of the 48 hour hot de-brief.”
judiciary.uk/…/freeda-glausiusz-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Freeda Glausiusz (20 Oct 2021) · stated timescale: May 2020
“In May 2020, immediately, after Ms [name redacted] death, the Deputy Borough Director listened to calls by each staff member to assess the quality of the care being provided.”
judiciary.uk/…/2023-0199-Response-from-East-London-NHS-Foundati…
Stated action 2 · response to Freeda Glausiusz (20 Oct 2021) · stated timescale: July 2021
“In July 2021, the Deputy Borough Director listened to recorded calls from each staff member working on the Crisis Line. The standard was overall good. However, the outcome was that the contract of an Agency Nurse was terminated and another nurse was commenced on a performance management process.”
judiciary.uk/…/2023-0199-Response-from-East-London-NHS-Foundati…
Stated action 3 · response to Freeda Glausiusz (20 Oct 2021) · stated timescale: 20 November 2021 - 28 November 2021
“Between 20 November 2021 - 28 November 2021, the CCG conducted a 'mystery shopping' audit of the Crisis line to measure responsiveness to calls. 70% of calls were answered in one minute or less, with 20% less than two minutes.”
judiciary.uk/…/2023-0199-Response-from-East-London-NHS-Foundati…
3 further stated actions are listed on the full chain page.
What recurred
- 25 Jan 2023 · Andrew Largin · Mary Hassell · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Freeda Glausiusz · 20 Oct 2021
“I never received a copy of the 48 hour hot de-brief.”
Later · Andrew Largin · 25 Jan 2023
“However, no notes were made of that and no entry was made on Mr [name redacted] medical record”
What happened next
No web check of the stated actions has been published for this chain.