Recurance · prevention of future deaths reports
Pre-inquest brief
Discharge without follow up arrangements
The earlier warning
Nicola Matthews · 20 Aug 2013 · Dr R N Palmer, London (South)
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented.”
judiciary.uk/prevention-of-future-death-reports/nicola-matthews
What was promised
No published response from South London and Maudsley NHS Foundation Trust was found for the earlier reports.
What recurred
- 9 May 2014 · Gary Richards · Andrew Harris · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Nicola Matthews · 20 Aug 2013
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented.”
Later · Gary Richards · 9 May 2014
“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded.”
What happened next
No web check of the stated actions has been published for this chain.