Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate dissemination of protocol changes to frontline staff
The earlier warning
Sally Perrons · 9 Apr 2014 · Heidi Connor, Nottinghamshire
“Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.”
judiciary.uk/prevention-of-future-death-reports/sally-perrons
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 31 Jan 2017 · Dipa Lad · Heidi Connor · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Sally Perrons · 9 Apr 2014
“Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.”
Later · Dipa Lad · 31 Jan 2017
“We heard that EMAS relies on emailing changes in protocols to staff. There is no check that busy staff have read and understood these, and there has been no training on this change.”
What happened next
No web check of the stated actions has been published for this chain.