Recurance · prevention of future deaths reports
Pre-inquest brief
Missing documentation and follow up in district nursing
The earlier warning
Anita Loi · 21 Feb 2020 · Jacqueline Devonish, London South
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
What was promised
Stated action 1 · response to Anita Loi (21 Feb 2020) · stated timescale: none stated
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”
judiciary.uk/…/2020-0067-Response-from-Central-London-Community…
What recurred
- 6 Mar 2026 · Asher Blackman · Andrew Walker · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Anita Loi · 21 Feb 2020
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
Later · Asher Blackman · 6 Mar 2026
“the initial assessment for Mr [name redacted] by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.”
What happened next
No web check of the stated actions has been published for this chain.