Paula Lenihan

1. 1. insufficient recording of risk

   “in addition to this present case, where the deceased's risk assessment was not updated between November 2021 and her death in March 2023 despite circumstances which I was told ought to have triggered an update, there were a further number of cases within the Trust in which Root Cause Analysis reports had been produced, where it had also been found that risk assessments were not being completed in line with expectations; further, that it was not clear why this was happening”

2. 2. deaths from insufficient risk recording

   “If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk. The fact that risk-relevant information may be recorded in the body of clinical notes is not reassuring, because a risk assessment or risk summary ought to capture the most salient risk information so that a professional looking quickly can absorb it; this is all the more important where professionals are under time”

3. 3. insufficient recording or updating of risk assessments

   “In my opinion action needs to be taken to prevent the occurrence or continuance of the issue within the trust around the insufficient recording or updating of risk assessments, or to eliminate or reduce the risk of death created by such circumstances”

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