Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of risk assessment documentation and updates
The earlier warning
Toni Piel · 9 Jul 2015 · Matthew Cox, Manchester (North)
“No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 28 Nov 2017 · John Lea · Lisa Hashmi · Closely related · confidence 0.90 (high)
- 12 Mar 2019 · Marjorie Gartside · Catherine McKenna · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Toni Piel · 9 Jul 2015
“No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”
Later · John Lea · 28 Nov 2017
“In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess.”
What happened next
No web check of the stated actions has been published for this chain.