Kenneth Rippon

“The serious incident investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with.”

“The delay in the investigation in this case is particularly concerning in a number of respects, not least in that it revealed problems in clinical record keeping, risk assessments and the consideration of hospital admission, lack of family/carer involvement, lack of comprehensive mental state examination/assessment including capacity, safeguarding and social needs and medication review and access to services.”

“Further one of the actions upon identification of a serious incident is to obtain, secure and preserve all relevant evidence. In this case the memory capture forms identified as being required in the immediate aftermath of the incident were not taken promptly and were seemingly only taken after I requested sight of them, several months after the incident and therefore when memories had already be- gun to fade. This was concerning given the identified problem of clinical record keeping at the time”