Recurance · prevention of future deaths reports
Pre-inquest brief
Absence of learning disability liaison nurse support
The earlier warning
Julie Barrow · 30 Sept 2019 · Alison Mutch, Manchester (South)
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people”
judiciary.uk/prevention-of-future-death-reports/julie-barrow
What was promised
Stated action 1 · response to Julie Barrow (30 Sept 2019) · stated timescale: June 2018
“In June 2018, NHS Improvement published Learning Disability Improvement Standards for NHS trusts in England'. The Standards are intended to help NHS trusts measure the quality of service they provide to people with learning disabilities, autism or both”
judiciary.uk/…/2019-0325-Response-from-The-Department-of-Health…
What recurred
- 13 May 2025 · Rose Harfleet · Karen Henderson · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Julie Barrow · 30 Sept 2019
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people”
Later · Rose Harfleet · 13 May 2025
“there was no consideration or offer given to [the deceased] or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse”
What happened next
No web check of the stated actions has been published for this chain.