Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of timely crisis team visits and communication
The earlier warning
Mark Daniels · 1 Jun 2015 · ME Hassell, London Inner (North)
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
judiciary.uk/prevention-of-future-death-reports/mark-daniels
What was promised
Stated action 1 · response to Mark Daniels (1 Jun 2015) · stated timescale: none stated
“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”
judiciary.uk/…/2015-0208-Response-by-Camden-and-Islington-NHS-T…
What recurred
- 24 Aug 2017 · Jonathan Meaney · ME Hassell · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mark Daniels · 1 Jun 2015
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
Later · Jonathan Meaney · 24 Aug 2017
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
What happened next
No web check of the stated actions has been published for this chain.