Recurance · prevention of future deaths reports
Pre-inquest brief
Insufficient mental health service engagement and follow-up
The earlier warning
Daniel Clements · 13 Jul 2022 · Kevin McLoughlin, West Yorkshire Western
“Mr [name redacted] was passed between agencies without any lasting benefit.”
judiciary.uk/…/daniel-clements-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Daniel Clements (13 Jul 2022) · stated timescale: none stated
“the Trust will propose a meeting with its social care partner, [name redacted] Authority, to raise with them the contents of your report.”
judiciary.uk/…/2022-0209-Response-from-South-West-Yorkshire-Par…
Stated action 2 · response to Mark Ravensdale (16 May 2023) · stated timescale: none stated
“The Trust will therefore develop and implement a triage checklist in respect of the review's findings.”
judiciary.uk/…/2025-0400-Response-from-South-West-Yorkshire-Par…
What recurred
- 16 May 2023 · Mark Ravensdale · Abigail Combes
- 24 Mar 2025 · Claire Driver · Tanya Rawden · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mark Ravensdale · 16 May 2023
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
Later · Claire Driver · 24 Mar 2025
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in”
What happened next
No web check of the stated actions has been published for this chain.