Recurance · prevention of future deaths reports
Pre-inquest brief
Risk assessment not updated after formulation meeting
The earlier warning
Michael McMonigle · 15 Aug 2016 · Crispin Oliver, County Durham and Darlington
“The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm and suicide and details of conditions for escorted leave following the formulation meeting on 10" August 2015”
What was promised
No published response from Tees was found for the earlier reports.
What recurred
- 20 Apr 2017 · Thomas Whitfield · Andrew Tweddle · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Michael McMonigle · 15 Aug 2016
“The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm and suicide and details of conditions for escorted leave following the formulation meeting on 10" August 2015”
Later · Thomas Whitfield · 20 Apr 2017
“There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.”
What happened next
No web check of the stated actions has been published for this chain.