Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate documentation and communication of discharge decisions
The earlier warning
Nicola Matthews · 20 Aug 2013 · Dr R N Palmer, London (South)
“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”
judiciary.uk/prevention-of-future-death-reports/nicola-matthews
What was promised
No published response from South London and Maudsley NHS Foundation Trust was found for the earlier reports.
What recurred
- 19 May 2026 · Catherine Morgan · Patricia Harding · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Nicola Matthews · 20 Aug 2013
“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”
Later · Catherine Morgan · 19 May 2026
“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth”
What happened next
No web check of the stated actions has been published for this chain.