Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of lead practitioner during transfer leading to lost follow up
The earlier warning
Paul Hyde · 5 Dec 2014 · Veronica Hamilton-Deeley, Brighton & Hove
“There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up”
What was promised
Stated action 1 · response to Paul Hyde (5 Dec 2014) · stated timescale: none stated
“A further action was a review of the triage function/process to include increased involvement from Consultant [name redacted] and additional members of ATS. All clinical triage meetings have a Consultant [name redacted], lead nurse, and administrator present. Following Mr [name redacted] neues Associate Specialist has been invited to attend the triage meetings on a regular basis.”
judiciary.uk/…/2014-0527-Response-by-Sussex-Partnership-NHS.pdf
Stated action 2 · response to George Rogers (27 Nov 2019) · stated timescale: 7 days
“Allocation of a Lead Practitioner of patients transferred from the CRHTT and ATS”
judiciary.uk/…/2019-0484-Response-from-Sussex-Partnership-NHS-F…
What recurred
- 27 Nov 2019 · George Rogers · Joanne Andrews
- 15 Mar 2021 · Timothy Steele · Veronica Hamilton-Deeley · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · George Rogers · 27 Nov 2019
“When transferring patients between the CHRTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment.”
Later · Timothy Steele · 15 Mar 2021
“Mr [name redacted] was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him.”
What happened next
No web check of the stated actions has been published for this chain.