Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate family involvement in care
The earlier warning
Amy El-Keria · 3 Oct 2016 · Penelope Schofield, East Sussex
“The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”
judiciary.uk/prevention-of-future-death-reports/amy-el-keria
What was promised
Stated action 1 · response to Amy El-Keria (3 Oct 2016) · stated timescale: 2009
“The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK. website at the following address: https://www.gov.uk/government/publications/assessing-and-managing-risk-in-”
judiciary.uk/…/2016-0347-Response-by-Department-of-Health.pdf
Stated action 2 · response to Amy El-Keria (3 Oct 2016) · stated timescale: none stated
“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”
Stated action 3 · response to Amy El-Keria (3 Oct 2016) · stated timescale: none stated
“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”
1 further stated action is listed on the full chain page.
What recurred
- 16 Aug 2019 · Justin Gallagher · Alan Craze · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Amy El-Keria · 3 Oct 2016
“The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”
Later · Justin Gallagher · 16 Aug 2019
“There was no involvement of the family and so a source of important information was missed.”
What happened next
No web check of the stated actions has been published for this chain.