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recurance

Felix Cembrowicz

12 Dec 2013 · Coroner Terence Moore · Avon

The coroner's concerns

  1. 1. incomplete patient history transfer

    “The electronic Rio record system used by staff to access patient histories was introduced in May 2011 when only the documentation for current patients at that date was migrated across to the new system. Discharged patients, with both a long and recent history of contact with mental health services do not appear to have had important records transferred including relapse management plans leaving staff unaware of a patients history or delaying assessments until old records can be obtained.”

Responses

2013-0204-Response-by-Avon-Wiltshire-NHS.pdf ↗· Avon and Wiltshire Mental Health Partnership NHS Trust

Stated action

“We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Felix Cembrowicz · Recurance