Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Harry Richford · 3 Feb 2020 · Christopher Sutton-Mattocks, North East Kent
“was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital.”
judiciary.uk/…/harry-richford-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Harry Richford (3 Feb 2020) · stated timescale: none stated
“the CQC continues to be in close contact with the Trust and will take regulatory action if it decides that it is necessary”
judiciary.uk/…/2020-0117-Response-from-Department-of-Health-and…
Stated action 2 · response to Harry Richford (3 Feb 2020) · stated timescale: none stated
“England and NHS Improvement (NHSEI) have put in place an intensive programme of support at the Trust”
judiciary.uk/…/2020-0117-Response-from-Department-of-Health-and…
Stated action 3 · response to Harry Richford (3 Feb 2020) · stated timescale: none stated
“The Trust must continue to strengthen its processes to learn from deaths and develop an open, learning culture for the safety of its patients”
judiciary.uk/…/2020-0117-Response-from-Department-of-Health-and…
2 further stated actions are listed on the full chain page.
What recurred
- 11 Jun 2025 · Lila Marsland · Chris Morris · Closely related · confidence 0.70 (moderate)
The clearest link, quoted from both reports:
Earlier · Harry Richford · 3 Feb 2020
“was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital.”
Later · Lila Marsland · 11 Jun 2025
“I am concerned that no medical record appears to exist of the examination of [the deceased] which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital.”
What happened next
No web check of the stated actions has been published for this chain.