Recurance · prevention of future deaths reports

Pre-inquest brief

Lack of formal mental health act assessment

Organisation: Norfolk and Suffolk NHS Foundation Trust · Generated: 27 Oct 2026

The earlier warning

Anthony Buckingham · 9 Apr 2019 · Daniel Sharpstone, Suffolk

“Formal mental health act assessment”

Stated action 1 · response to Anthony Buckingham (9 Apr 2019) · stated timescale: none stated

“Daily visits from the mental health team”

Stated action 2 · response to Anthony Buckingham (9 Apr 2019) · stated timescale: none stated

“The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews”

Stated action 3 · response to Anthony Buckingham (9 Apr 2019) · stated timescale: none stated

“The report doesn't identify at which stage of care a request for a mental health act assessment may have been appropriate”

2 further stated actions are listed on the full chain page.

12 Dec 2019 · Peter Frosdick · Yvonne Blake · Closely related · confidence 0.80 (moderate)

The clearest link, quoted from both reports:

Earlier · Anthony Buckingham · 9 Apr 2019

“Formal mental health act assessment”

Later · Peter Frosdick · 12 Dec 2019

“no-one appeared to have looked at his mental health except to note that he was alcohol dependant”

No web check of the stated actions has been published for this chain.