Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Graeme Kidd · 23 Jul 2014 · Jacqueline Lake, Norfolk
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
What was promised
Stated action 1 · response to David Read (8 Feb 2017) · stated timescale: none stated
“The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending their appointment they can speak to someone.”
judiciary.uk/…/2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Tr…
Stated action 2 · response to Eliot Harris (22 Aug 2022) · stated timescale: three months
“The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse- in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. [name redacted] to this aspect the trust is formulating a seminar on shift co-ordination and”
judiciary.uk/…/2022-0260-Response-form-Norfolk-and-Suffolk-Foun…
Stated action 3 · response to Ellen Woolnough (28 Mar 2024) · stated timescale: end of June 2024
“The Trust has recently been reviewing and updating their Clinical Risk Assessment and Management Policy. This Policy is currently progressing through Trust internal governance processes and is due to be published end of June 2024, with a Policy implementation plan to be progressed during July/August 2024.”
judiciary.uk/…/2024-0184-Response-from-Norfolk-and-Suffolk-NHS-…
What recurred
- 8 Feb 2017 · David Read · Jacqueline Lake
- 22 Aug 2022 · Eliot Harris · Jaqueline Lake · Closely related · confidence 0.90 (high)
- 28 Mar 2024 · Ellen Woolnough · Darren Stewart
- 9 Oct 2024 · Nigel Hammond · Nigel Parsley · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Graeme Kidd · 23 Jul 2014
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
Later · Eliot Harris · 22 Aug 2022
“It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out”
What happened next
No evidence found either way · stated action 1
“Posts by our comms team. Please don't leave urgent messages or messages concerned with your care - for urgent help, call 111 and select Mental Health option.”
Norfolk and Suffolk NHS FT | Norwich · facebook.com/p/Norfolk-and-Suffolk-NHS-FT-61583606955690
“the effectiveness of services. The service now had a 24-hour urgent mental health helpline (111 service) for professionals and the general public and people who used services to access crisis services.”
Norfolk and Suffolk NHS Foundation Trust - Care Quality Commission · cqc.org.uk/provider/RMY/inspection-summary
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Clinical Risk Assessment and Management Policy Services Applicable Trustwide x Mental Health and LD Community Health Services Version number : 5.0 Consultation Groups The Quality Committee membership and staff involved in complaint investigation and handling Approved by (Sponsor Group) The Quality Committee Ratified by: The Quality Committee Date ratified: 14th October 2020 Name of originator/aut”
[PDF] Clinical Risk Assessment and Management Policy · elft.nhs.uk/…/4499_appendix_3_-_clinical_risk_assessment_and_ma…
No evidence found does not mean the action did not happen.