Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate communication between health care departments
The earlier warning
David Ball · 24 Nov 2020 · Emma Serrano, Derby and Derbyshire
“Different health care departments have different patient care records and the departments did not communicate with one another.”
What was promised
Stated action 1 · response to David Ball (24 Nov 2020) · stated timescale: none stated
“We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.”
judiciary.uk/…/2020-0251-Response-from-NHS-Digital-Redacted.pdf
What recurred
- 14 Jul 2023 · Peter Fleming · James Bennett · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · David Ball · 24 Nov 2020
“Different health care departments have different patient care records and the departments did not communicate with one another.”
Later · Peter Fleming · 14 Jul 2023
“different health organisations use different digital systems that do not communicate with each other.”
What happened next
No web check of the stated actions has been published for this chain.