Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate verification of leave conditions
The earlier warning
Katy Samuels · 11 Dec 2020 · Delroy Henry, Coventry
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment”
judiciary.uk/prevention-of-future-death-reports/katy-samuels
What was promised
Stated action 1 · response to Katy Samuels (11 Dec 2020) · stated timescale: none stated
“The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation”
judiciary.uk/…/2020-0282-Response-from-Coventry-and-Warwickshir…
What recurred
- 4 Nov 2024 · Darren Hope · Linda Lee · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Katy Samuels · 11 Dec 2020
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment”
Later · Darren Hope · 4 Nov 2024
“Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave.”
What happened next
No web check of the stated actions has been published for this chain.