Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete patient leave documentation
The earlier warning
Adam Carter · 12 Jul 2018 · Alan Wilson, Blackpool & Fylde
“e Hecould not find a copy of the Leave Authorisation that granted [the deceased] leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.”
What was promised
Stated action 1 · response to Adam Carter (12 Jul 2018) · stated timescale: 28 September 2018
“The senior matron and lead nurse will establish how these prompts are implemented by 28 September 2018.”
judiciary.uk/…/2018-0226-Response-by-Lancashire-Care-NHS-Trust.…
What recurred
- 6 Feb 2020 · David Clark · Neil Cronin · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Adam Carter · 12 Jul 2018
“e Hecould not find a copy of the Leave Authorisation that granted [the deceased] leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.”
Later · David Clark · 6 Feb 2020
“(1) That documentation in relation to leave was not completed fully and incorrect forms used”
What happened next
No web check of the stated actions has been published for this chain.