Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of multidisciplinary coordination of care
The earlier warning
Maureen Wharton · 6 Dec 2019 · Terence Carney, Gateshead & South Tyneside
“No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.”
judiciary.uk/prevention-of-future-death-reports/maureen-wharton
What was promised
Stated action 1 · response to Richard Burgess (19 May 2021) · stated timescale: 27 July 2021
“the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”
judiciary.uk/…/2021-0163-Response-from-St-Nicholas-Hospital-Pub…
What recurred
- 19 May 2021 · Richard Burgess · Derek Winter
- 29 Feb 2024 · Christopher Vickers · Leila Benyounes · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Richard Burgess · 19 May 2021
“- the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;”
Later · Christopher Vickers · 29 Feb 2024
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
What happened next
No web check of the stated actions has been published for this chain.