Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate audit of observations and documentation
The earlier warning
Stephanie Daniels · 13 Dec 2013 · Nigel Meadows, Manchester City
“without appropriate audit and clinical/nursing leadership this may prove to be ineffective.”
What was promised
Stated action 1 · response to Stephanie Daniels (13 Dec 2013) · stated timescale: none stated
“the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases.”
judiciary.uk/…/2013-0353-Response-by-Manchester-Mental-Health-N…
Stated action 2 · response to Jude Lloyd (4 Oct 2021) · stated timescale: none stated
“The Trust's RCA report highlighted that in respect of inpatient monitoring of Mr [name redacted] diabetes, the care plans and risk assessments were completed on signs and symptoms of hypoglycaemia, but it was recognised these were not tailored to Mr [name redacted] specific needs. A further recommendation was to raise awareness and education on monitoring for signs of diabetic ketoacidosis for CMHT staff. To address this an eLearning training package is in place in respect of supporting and monitoring physical”
judiciary.uk/…/2021-0329-Response-from-Greater-Manchester-Menta…
What recurred
- 4 Oct 2021 · Jude Lloyd · Nigel Meadows · Closely related · confidence 0.90 (high)
- 1 Nov 2022 · Rowan Thompson · Joanne Kearsley · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jude Lloyd · 4 Oct 2021
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”
Later · Rowan Thompson · 1 Nov 2022
“System by which observations and documentation are audited lacks rigour and is ineffective.”
What happened next
No web check of the stated actions has been published for this chain.