Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate risk assessment documentation and undocumented risk disclosures
The earlier warning
Richard Jones · 20 Feb 2015 · Ian Singleton, Wiltshire & Swindon
“As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”
judiciary.uk/prevention-of-future-death-reports/richard-jones
What was promised
Stated action 1 · response to Richard Jones (20 Feb 2015) · stated timescale: none stated
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
judiciary.uk/…/2015-0068-Response-by-Ministry-of-Defence.pdf
What recurred
- 19 Nov 2020 · Paul Hills · Sonia Hayes · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Richard Jones · 20 Feb 2015
“As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”
Later · Paul Hills · 19 Nov 2020
“His risk assessment was not up-to-date and his disclosures during April were not documented.”
What happened next
No web check of the stated actions has been published for this chain.