Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed access to medical records
The earlier warning
Fiona Humberstone · 28 Jun 2021 · Sean Horstead, Essex
“does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication)”
What was promised
No published response from Essex Partnership University NHS Foundation Trust was found for the earlier reports.
What recurred
- 17 Feb 2025 · David Bennett · Sonia Hayes · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Fiona Humberstone · 28 Jun 2021
“does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication)”
Later · David Bennett · 17 Feb 2025
“The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse.”
What happened next
No web check of the stated actions has been published for this chain.