Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Colin Moulton · 10 Jul 2015 · Simon Nelson, Manchester (North)
“When Mr [name redacted] was admitted to A & E on the 13”
judiciary.uk/prevention-of-future-death-reports/colin-moulton
What was promised
Stated action 1 · response to Colin Moulton (10 Jul 2015) · stated timescale: none stated
“the Trust has now implemented improved handover procedures between paramedics and A&E staff which should ensure that the triage nurse sees any patient notes made by the paramedics and documents this action.”
judiciary.uk/…/2015-0267-Response-by-Department-of-Health.pdf
Stated action 2 · response to Colin Moulton (10 Jul 2015) · stated timescale: none stated
“NWAS has advised that its staff always leave a patient report form (PRF) at every hospital following a patient transfer. A copy of this form also remains with the patient following admission”
judiciary.uk/…/2015-0267-Response-by-Department-of-Health.pdf
Stated action 3 · response to Colin Moulton (10 Jul 2015) · stated timescale: none stated
“FGH has very specific patient handover procedures which require NWAS to leave a copy of the PRF with the hospital receptionist for placing with hospital documentation which is subsequently passed to the triage nurse once the patient has been booked in”
judiciary.uk/…/2015-0267-Response-by-Department-of-Health.pdf
What recurred
- 24 Jul 2024 · Regan Smith · Nigel Parsley · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Colin Moulton · 10 Jul 2015
“When Mr [name redacted] was admitted to A & E on the 13”
Later · Regan Smith · 24 Jul 2024
“Evidence heard that the handover system in [the deceased]'s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover.”
What happened next
No web check of the stated actions has been published for this chain.