Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate cell sharing risk assessment for epilepsy and sexual orientation
The earlier warning
David O'Garro · 16 Jun 2014 · ME Hassell, London Inner (North)
“The nurse who carried out the first reception screen of Mr [name redacted] did not complete a cell sharing risk assessment (CSRA)”
judiciary.uk/prevention-of-future-death-reports/david-ogarro
What was promised
No published response from HMP Pentonville was found for the earlier reports.
What recurred
- 31 Oct 2017 · Vilhelmas Borkertas · ME Hassell · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · David O'Garro · 16 Jun 2014
“The nurse who carried out the first reception screen of Mr [name redacted] did not complete a cell sharing risk assessment (CSRA)”
Later · Vilhelmas Borkertas · 31 Oct 2017
“Mr [name redacted] described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form.”
What happened next
No web check of the stated actions has been published for this chain.