Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of communication between specialties
The earlier warning
Calogero Di Blasi · 15 Nov 2023 · Debbie Rookes, Avon
“That one of the teams caring for Mr [name redacted] was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway.”
judiciary.uk/…/calogero-di-blasi-prevention-of-future-deaths-re…
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 20 Dec 2024 · Antony Williamson · Adrian Farrow · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Calogero Di Blasi · 15 Nov 2023
“That one of the teams caring for Mr [name redacted] was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway.”
Later · Antony Williamson · 20 Dec 2024
“Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr [name redacted] care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.”
What happened next
No web check of the stated actions has been published for this chain.