Recurance · prevention of future deaths reports
Pre-inquest brief
Carers not advised of suicide risk behaviours
The earlier warning
Joshua Brown · 17 Jul 2014 · Rebecca Cobb, North East Kent
“The evidence was that Mr [name redacted] lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr [name redacted] did not wish information about him to be shared.”
judiciary.uk/prevention-of-future-death-reports/joshua-brown
What was promised
Stated action 1 · response to Joanna Bowring (27 Jan 2016) · stated timescale: February 2016
“the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”
Stated action 2 · response to Joanna Bowring (27 Jan 2016) · stated timescale: ongoing
“The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care”
Stated action 3 · response to Joanna Bowring (27 Jan 2016) · stated timescale: February 2016
“The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for”
1 further stated action is listed on the full chain page.
What recurred
- 27 Jan 2016 · Joanna Bowring · Patricia Harding
- 20 Sept 2022 · Robert Brown · Joanne Andrews
- 4 Mar 2024 · Sarah Keen · Patricia Harding · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Robert Brown · 20 Sept 2022
“Carer breakdown is likely to have increased the risks of suicidality on discharge as this was not addressed during the hospital admission nor on discharge”
Later · Sarah Keen · 4 Mar 2024
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health”
What happened next
No web check of the stated actions has been published for this chain.