Recurance · prevention of future deaths reports
Pre-inquest brief
Unclear hospital transfer process and forms
The earlier warning
Dean Saunders · 17 Feb 2017 · Caroline Beasley-Murray, Essex
“The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”
judiciary.uk/prevention-of-future-death-reports/dean-saunders
What was promised
Stated action 1 · response to Dean Saunders (17 Feb 2017) · stated timescale: none stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
What recurred
- 13 Dec 2017 · Rebecca Romero · Maria Voisin · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Dean Saunders · 17 Feb 2017
“The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”
Later · Rebecca Romero · 13 Dec 2017
“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure.”
What happened next
Evidence found · stated action 1
“The commissioning of Healthcare for Police Custody Suites is to transfer to NHS England by 2016. This work will continue to be developed and”
Health and Justice Commissioning Intentions 2015/16 · england.nhs.uk/…/hj-comms-ints-refresh.pdf