Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of rolling risk assessment documentation in SystemOne
The earlier warning
Jai Singh · 15 Mar 2023 · Emma Brown, Birmingham and Solihull
“No such facility is in use on SystemOne at HMP Birmingham.”
What was promised
Stated action 1 · response to Jai Singh (15 Mar 2023) · stated timescale: none stated
“Matters of Concern: The absence of ongoing risk assessment documentation for patients with mental illness within SystmOne records at HMP Birmingham.”
Stated action 2 · response to Jai Singh (15 Mar 2023) · stated timescale: 3 month pilot
“The Trust has begun a 3 month pilot which will ensure a Consultant [name redacted] attends the 3 MDT meetings at the Prison each week. The Secure Care and Offender Health Clinical Governance Committee (CGC) will review the outcomes for the pilot after 3 months, to ascertain if this is clinically beneficial to patients”
judiciary.uk/…/2023-0094-Response-from-Birmingham-and-Solihull-…
What recurred
- 2 Oct 2023 · Paula Lenihan · Susanna Rickard · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jai Singh · 15 Mar 2023
“No such facility is in use on SystemOne at HMP Birmingham.”
Later · Paula Lenihan · 2 Oct 2023
“If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk.”
What happened next
No web check of the stated actions has been published for this chain.