Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Patricia Cleghorn · 25 Jul 2016 · Louise Hunt, Birmingham and Solihull
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.”
What was promised
Stated action 1 · response to Patricia Cleghorn (25 Jul 2016) · stated timescale: December 2016
“We will be meeting with the Trust again in December 2016 to review the impact of their action plans.”
judiciary.uk/…/2016-0270-Response-by-Care-Quality-Commission.pdf
Stated action 2 · response to Patricia Cleghorn (25 Jul 2016) · stated timescale: 2020/21
“NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and community/primary care work streams. The acute care work stream has been developed in response to a number of recommendations set out by the Commission on Acute Adult Psychiatric Care and The Five Year Forward View for Mental Health, and is particularly relevant to the concerns outlined in your report.”
What recurred
- 5 Apr 2019 · Yong Hong · Sonia Hayes · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Patricia Cleghorn · 25 Jul 2016
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.”
Later · Yong Hong · 5 Apr 2019
“(c) no risk assessment was carried out prior to making the decision to return his call bell.”
What happened next
No evidence found either way · stated action 2
“The Commission to review the provision of acute inpatient psychiatric care for adults FEBRUARY 2016 OLD PROBLEMS, NEW SOLUTIONS: Improving acute psychiatric care for adults in England FINAL REPORT Old Problems, New Solutions: Improving Acute Psychiatric Care for Adults in England Published: February 2016 The independent Commission on Acute Adult Psychiatric Care was set up by the Royal College of”
OLD PROBLEMS, NEW SOLUTIONS: · rcpsych.ac.uk/…/policy-old-problems-new-solutions-caapc-report-…
“Mental Health - Adult Crisis and Acute Care GIRFT Programme National Specialty Report By Dr [name redacted] GIRFT Clinical Lead April 2021 GIRFT is delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust, NHS England and NHS Improvement 2 Contents Foreword................................................................................................................”
Mental Health – Adult Crisis and Acute Care · gettingitrightfirsttime.co.uk/…/Mental-Health-Sept21i.pdf
“CLINICAL PERFORMANCE STANDARDS Extended Acute Care (EAC) Services Updated March 2026 CPS: EXTENDED ACUTE CARE (EAC) SERVICES Updated March 2026 2 TABLE OF CONTENTS 1. Purpose ......................................................................................................................................................... 3 2. Scope of Services ..................................”
Extended Acute Care (EAC) Services · cbhphilly.org/wp-content/uploads/2022/10/CBH_CPS_EAC_2026-03.pdf
No evidence found does not mean the action did not happen.