Inadequate risk information sharing and documentation

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2015 → 2024Charlie Owen9 years 9 months after Richard Jones · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight problems with sharing and documenting risk-related information about armed forces personnel with mental health needs. The earlier report focuses on inter‑agency transmission of risk details, while the later report notes insufficient detail in case conference notes and VRM process documentation.

  Richard Jones · 20 Feb 2015

  “As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”

  Check it in the source

  Charlie Owen · 29 Nov 2024

  “The lack of detail contained within the case conference notes hindered this inquest's ability to establish precisely what risk information was shared.”

  Check it in the source

  Stated action in the response to the earlier report

  “we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”

  Earlier report in the app · Later report in the app