Recurance · prevention of future deaths reports
Pre-inquest brief
Poor record keeping in missing person investigations
The earlier warning
Edith Robinson · 19 Jul 2017 · Lisa Hashmi, Manchester (North)
“the standard of record keeping by both doctors and nurses was poor.”
judiciary.uk/prevention-of-future-death-reports/edith-robinson
What was promised
Stated action 1 · response to Edith Robinson (19 Jul 2017) · stated timescale: none stated
“the Trust has agreed that all patients will be reviewed daily by the medical team and that the Trust is currently looking to ensure that all trauma patients with severe systemic illness will be reviewed daily by a medical doctor. This will be monitored through Trust audits.”
Stated action 2 · response to Thomas Jackson (13 Nov 2018) · stated timescale: 8 January 2019
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated action 3 · response to Thomas Jackson (13 Nov 2018) · stated timescale: none stated
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
What recurred
- 13 Nov 2018 · Thomas Jackson · Andrew Haigh · Identical hazard · confidence 0.95 (high)
- 21 Jul 2022 · Gaia Pope-Sutherland · Rachael Griffin · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Edith Robinson · 19 Jul 2017
“the standard of record keeping by both doctors and nurses was poor.”
Later · Thomas Jackson · 13 Nov 2018
“During the hearing it was noted that on a number of occasions record keeping was poor.”
What happened next
No web check of the stated actions has been published for this chain.