Recurance · prevention of future deaths reports
Pre-inquest brief
Healthcare staff absent during ACCT reviews
The earlier warning
John Delahaye · 18 Dec 2018 · Emma Brown, Birmingham and Solihull
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
judiciary.uk/prevention-of-future-death-reports/john-delahaye
What was promised
Stated action 1 · response to John Delahaye (18 Dec 2018) · stated timescale: 1% February 2019
“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”
judiciary.uk/wp-content/uploads/2019/05/2018-0388-Responses.pdf
What recurred
- 16 May 2023 · Stuart Robinson · Kate Ainge · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · John Delahaye · 18 Dec 2018
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Later · Stuart Robinson · 16 May 2023
“question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending.”
What happened next
No web check of the stated actions has been published for this chain.