Recurance · prevention of future deaths reports
Pre-inquest brief
Outdated care plan and risk assessment
The earlier warning
Paul Hills · 19 Nov 2020 · Sonia Hayes, North East Kent
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
What was promised
Stated action 1 · response to Paul Hills (19 Nov 2020) · stated timescale: April 2021
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated action 2 · response to Paul Hills (19 Nov 2020) · stated timescale: none stated
“all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”
What recurred
- 6 Dec 2021 · Alexander Tostevin · Brendan Allen · Closely related · confidence 0.78 (moderate)
The clearest link, quoted from both reports:
Earlier · Paul Hills · 19 Nov 2020
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
Later · Alexander Tostevin · 6 Dec 2021
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
What happened next
No web check of the stated actions has been published for this chain.