Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of serious incident review and mandatory root cause analysis training
The earlier warning
Nadim Butt · 7 Apr 2016 · Ian Smith, Stoke-on-Trent and North Staffordshire
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
What was promised
No published response from University Hospital of North Midlands was found for the earlier reports.
What recurred
- 19 Apr 2021 · Stephen Oakes · Margaret Jones · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Nadim Butt · 7 Apr 2016
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
Later · Stephen Oakes · 19 Apr 2021
“(5) There is no compulsory training of clinicians required to undertake root cause analysis.”
What happened next
No web check of the stated actions has been published for this chain.