Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of care plan coordination
The earlier warning
Dorothy Imisson · 5 Apr 2016 · James Adeley, Preston and West Lancashire
“No appropriate care plan was developed by the District Nursing Service.”
judiciary.uk/prevention-of-future-death-reports/dorothy-imisson
What was promised
No published response from Care Quality Commission was found for the earlier reports.
What recurred
- 6 Sept 2019 · Shannon Quinn · Zafar Siddique · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Dorothy Imisson · 5 Apr 2016
“No appropriate care plan was developed by the District Nursing Service.”
Later · Shannon Quinn · 6 Sept 2019
“There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.”
What happened next
No web check of the stated actions has been published for this chain.