Incomplete risk assessment documentation and communication

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.

• 2014 → 2020Benjamin Popovach6 years 3 months after Elaine Jobe · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight deficiencies in the completion and documentation of risk assessments for patients.

  Elaine Jobe · 14 Jul 2014

  “lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”

  Check it in the source

  Benjamin Popovach · 23 Oct 2020

  “Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”

  Earlier report in the app · Later report in the app

• 2014 → 2022Archi Johnson8 years after Elaine Jobe · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight problems with how risk assessment information is recorded and communicated within the trust. The earlier report cites a general lack of record‑keeping for assessments and observer details, while the later report notes that crucial incident data is omitted from the assessments used by staff.

  Elaine Jobe · 14 Jul 2014

  “lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”

  Check it in the source

  Archi Johnson · 26 Jul 2022

  “Two types of risk assessments were completed, with no system to ensure that important information is present on both;”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”

  Earlier report in the app · Later report in the app

• 2014 → 2023Paul Perrott9 years 5 months after Elaine Jobe · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures in documenting and tracking patient observations, specifically missing or incomplete records of observation charts and who performed them.

  Elaine Jobe · 14 Jul 2014

  “Lack of information regarding the Levels of Observations and the persons actually making the observations.”

  Check it in the source

  Paul Perrott · 11 Dec 2023

  “[the deceased]'s observations charts were not filled out adequately or at all on the date of his death”

  Check it in the source

  Earlier report in the app · Later report in the app