Recurance · prevention of future deaths reports
Pre-inquest brief
Reliance on informal assurances leading to missed referrals
The earlier warning
David Chatburn · 18 Mar 2014 · L J Hashmi, Manchester (North)
“That the GP felt it was sufficient for him to simply discuss the deceased's care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process.”
judiciary.uk/prevention-of-future-death-reports/david-chatburn
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 16 Feb 2017 · Thomas Green · Joanne Kearsley
- 30 Nov 2017 · Lindsey Hassall · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Thomas Green · 16 Feb 2017
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
Later · Lindsey Hassall · 30 Nov 2017
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made.”
What happened next
No web check of the stated actions has been published for this chain.