Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete national early warning system scoring
The earlier warning
Thelma Jones · 12 Aug 2015 · Veronica Hamilton-Deeley, Brighton and Hove
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed.”
judiciary.uk/prevention-of-future-death-reports/thelma-jones
What was promised
Stated action 1 · response to Thelma Jones (12 Aug 2015) · stated timescale: 7 November 2015
“We have carried out a careful review of the medical records with the appropriate personnel.”
judiciary.uk/…/2015-0318-Response-by-Brighton-and-Sussex-Univer…
Stated action 2 · response to Diana Ritchie (18 Aug 2016) · stated timescale: none stated
“The Trust has also established a specific working group entitled”
judiciary.uk/…/2016-0296-Response-by-Brighton-and-Sussex-Univer…
What recurred
- 18 Aug 2016 · Diana Ritchie · Veronica Hamilton-Deeley · Closely related · confidence 0.85 (high)
- 10 Dec 2019 · Frances Gibb · Veronica Hamilton-Deeley · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Thelma Jones · 12 Aug 2015
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed.”
Later · Frances Gibb · 10 Dec 2019
“(1) Once again | must write concerning the serious failings in the use of NEWS. Please see the Record of Inquest for details.”
What happened next
No web check of the stated actions has been published for this chain.