Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Emma Carpenter · 14 Jul 2015 · Stephanie Haskey, Nottinghamshire
“Inthe absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents”
judiciary.uk/prevention-of-future-death-reports/emma-carpenter
What was promised
Stated action 1 · response to Emma Carpenter (14 Jul 2015) · stated timescale: 8 September 2015
“The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen's Medical Centre, there are no equivalent links with Bassetlaw Hospital.”
judiciary.uk/wp-content/uploads/2015/10/Carpenter-2015-0276a.pdf
Stated action 2 · response to Emma Carpenter (14 Jul 2015) · stated timescale: none stated
“We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team.”
judiciary.uk/…/2015-0276-Response-by-Doncaster-and-Bassettlaw-H…
What recurred
- 14 Feb 2024 · Alfie Nicholls · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Emma Carpenter · 14 Jul 2015
“Inthe absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents”
Later · Alfie Nicholls · 14 Feb 2024
“The Inquest heard that the school nurse service could play a vital role in identifying health issues and supporting other professionals.”
What happened next
No evidence found either way · stated action 1
The Trust described a specialist eating disorder service for children and adolescents with professional links to paediatricians at Kings Mill Hospital and Queen's Medical Centre but no equivalent links with Bassetlaw Hospital.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“The recommendation of assurance from the Executive team.”
10 Date of meeting: 20 May 2026 Report to the: Trust Board ... · eastofenglandcommunityhealthandcare.nhs.uk/…/100-trust-board-in…
No evidence found does not mean the action did not happen.