Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Gerard Murray · 1 Sept 2023 · Elizabeth Didcock, Nottinghamshire
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
judiciary.uk/…/gerard-murray-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Gerard Murray (1 Sept 2023) · stated timescale: none stated
“To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”
judiciary.uk/…/2023-0391-Response-from-Nottingham-Heathcare.pdf
Stated action 2 · response to Gerard Murray (1 Sept 2023) · stated timescale: none stated
“an electronic device is being procured which will allow multiple alarms to be set for each person's leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot.”
judiciary.uk/…/2023-0391-Response-from-Nottingham-Heathcare.pdf
Stated action 3 · response to Gerard Murray (1 Sept 2023) · stated timescale: none stated
“The Triangle of care process has also been strengthened as part of our ongoing quality improvement plans. Our Quality Standards Team also undertake reviews of Care Plans and look for clear evidence that these plans are produced with the patient, family and carers.”
judiciary.uk/…/2023-0391-Response-from-Nottingham-Heathcare.pdf
3 further stated actions are listed on the full chain page.
What recurred
- 4 Mar 2024 · Kenneth Baylis · Elizabeth Didcock · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Gerard Murray · 1 Sept 2023
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
Later · Kenneth Baylis · 4 Mar 2024
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”
What happened next
No web check of the stated actions has been published for this chain.