Recurance · prevention of future deaths reports
Pre-inquest brief
Overdue CPA meetings and missing discharge care plans
The earlier warning
Lewis Colgan · 9 May 2018 · Crispin Butler, Buckinghamshire
“There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these.”
judiciary.uk/prevention-of-future-death-reports/lewis-colgan
What was promised
No published response from Oxford Health NHS Foundation Trust was found for the earlier reports.
What recurred
- 29 Mar 2021 · Roy Morris · Crispin Butler · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Lewis Colgan · 9 May 2018
“There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these.”
Later · Roy Morris · 29 Mar 2021
“The application of the CPA policy for patients such as [the deceased] so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting.”
What happened next
No web check of the stated actions has been published for this chain.