Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate foreign body management guidance
The earlier warning
Tammy Watkins · 5 Jan 2024 · Laurinda Bower, Nottingham and Nottinghamshire
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.”
judiciary.uk/…/tammy-watkins-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Tammy Watkins (5 Jan 2024) · stated timescale: next 12 months
“The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”
judiciary.uk/…/2024-0017-Response-from-Nottinghamshire-Healthca…
What recurred
- 24 Oct 2025 · Sophie Towle · Alexandra Poutney · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Tammy Watkins · 5 Jan 2024
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.”
Later · Sophie Towle · 24 Oct 2025
“I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance.”
What happened next
No web check of the stated actions has been published for this chain.