Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate documentation of clinical decisions
The earlier warning
Nuala Seddon · 6 Feb 2017 · R Brittain, London Inner (North)
“It seems clear that a decision was made to transfer Mrs [name redacted] from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff.”
judiciary.uk/prevention-of-future-death-reports/nuala-seddon
What was promised
Stated action 1 · response to Nuala Seddon (6 Feb 2017) · stated timescale: 3 April 2017
“I am R Brittain, Assistant Coroner for Inner London North.”
judiciary.uk/wp-content/uploads/2017/02/Seddon-2017-0034a.pdf
What recurred
- 13 May 2024 · Elvon Morton · Graeme Irvine · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Nuala Seddon · 6 Feb 2017
“It seems clear that a decision was made to transfer Mrs [name redacted] from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff.”
Later · Elvon Morton · 13 May 2024
“The decision to sedate Mr [name redacted] was flawed. The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
What happened next
No evidence found either way · a stated action in a response
“Contrast: [](/)”
Key documents - Barts Health NHS Trust · bartshealth.nhs.uk/key-documents
No evidence found does not mean the action did not happen.