Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of integrated multidisciplinary care across sites
The earlier warning
Ann Swoffer · 22 Jan 2019 · Louise Hunt, Birmingham and Solihull
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols.”
What was promised
Stated action 1 · response to Ann Swoffer (22 Jan 2019) · stated timescale: June 2019
“The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019.”
judiciary.uk/…/2019-0026-Response-by-University-Hospitals-Birmi…
What recurred
- 30 Jun 2023 · Sinon Masha · Emma Brown · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Ann Swoffer · 22 Jan 2019
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols.”
Later · Sinon Masha · 30 Jun 2023
“Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding.”
What happened next
No web check of the stated actions has been published for this chain.