Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate clinical documentation of patient condition and decisions
The earlier warning
Evelyn Ross · 27 Apr 2020 · Alison Mutch, Greater Manchester South
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
What was promised
Stated action 1 · response to Evelyn Ross (27 Apr 2020) · stated timescale: deferred until operational effort to COVID-19 response
“The NHS published the Interim People Plan1 in June 2019 that sets out the long-term vision and immediate actions to meet the challenges of workforce supply, reform, culture and leadership. Publication of the final NHS People Plan has been deferred so that the NHS is able to devote its full operational effort to the COVID-19 response. However, when published, the final NHS People Plan will set out further actions to secure the NHS staff we need in the future.”
judiciary.uk/…/2020-0106-Response-from-Department-of-Health-and…
What recurred
- 25 Oct 2024 · Chloe Every · Graeme Irvine · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Evelyn Ross · 27 Apr 2020
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
Later · Chloe Every · 25 Oct 2024
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment. The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located.”
What happened next
No web check of the stated actions has been published for this chain.