Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
2018-0405 · 21 Dec 2018 · John Ellery, Shropshire, Telford and Wrekin
“Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand”
What was promised
Stated action 1 · response to 2018-0405 (21 Dec 2018) · stated timescale: 14th November 2017
“Following discussions within the teams involved, I ani now in a position to respond to your specific concerns, where by you. stated you heard at the inquest during the course of the evidence: 1. Delay in IAPT Counselling After turned 18 she moved to Adult Mental Health Services. She had parallel contact with her GP surgery in Shortly before 18th birthday according to the MPFT Clinical Review I (page 9 of 33), was referred to Improving Access to Psychological Therapies (IAPT) . by'the Access Team for”
judiciary.uk/…/2018-0405-Response-from-Midlands-Partnership-NHS…
Stated action 2 · response to Jamie Pilkington (22 Feb 2024) · stated timescale: December 2023
“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”
judiciary.uk/…/2024-0101-Response-from-Midlands-Partnership-NHS…
Stated action 3 · response to Jamie Pilkington (22 Feb 2024) · stated timescale: December 2023
“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”
judiciary.uk/…/2024-0101-Response-from-Midlands-Partnership-NHS…
4 further stated actions are listed on the full chain page.
What recurred
- 22 Feb 2024 · Jamie Pilkington · Andrew Barkley · Closely related · confidence 0.85 (high)
- 19 Mar 2025 · William Grieve · Emma Serrano · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jamie Pilkington · 22 Feb 2024
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
Later · William Grieve · 19 Mar 2025
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.”
What happened next
No evidence found either way · stated action 3
“Patient safety incident response plan Summary This plan describes how the trust will respond to patient safety incidents, in accordance with the Patient Safety Incident Response Framework (PSIRF) and national reporting requirements.”
Patient safety incident response plan 2026 · moorfields.nhs.uk/…/patient-safety-incident-response-plan-versi…
No evidence found does not mean the action did not happen.