Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete risk assessment before discharge
The earlier warning
Evelina Vilkiene · 6 Mar 2023 · Nadia Persaud, East London
“When [the deceased] was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.”
judiciary.uk/…/evelina-vilkiene-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Evelina Vilkiene (6 Mar 2023) · stated timescale: none stated
“We have detailed the actions which we will take, within the attached action plan, for your kind consideration”
judiciary.uk/…/2023-0082-Response-from-North-East-London-Founda…
Stated action 2 · response to Carol Robinson (30 Mar 2023) · stated timescale: none stated
“we attach a detailed action plan addressing the concerns raised by you.”
judiciary.uk/…/2023-0111-Response-from-North-East-London-Founda…
Stated action 3 · response to James Agius (7 Oct 2024) · stated timescale: 2024-11-03
“The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.”
What recurred
- 30 Mar 2023 · Carol Robinson · Nadia Persaud
- 7 Oct 2024 · James Agius · Sonia Hayes · Closely related · confidence 0.90 (high)
- 23 May 2025 · George Fraser · Nadia Persaud · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Carol Robinson · 30 Mar 2023
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
Later · James Agius · 7 Oct 2024
“The medical record documentation for Mr [name redacted] had significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted]”
What happened next
No web check of the stated actions has been published for this chain.