Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of discharge planning in mental health services
The earlier warning
Gareth Slater · 30 Jan 2014 · Joanne Kearsley, Manchester (South)
“The discharge planning in relation to Mr [name redacted] was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this.”
judiciary.uk/prevention-of-future-death-reports/gareth-slater
What was promised
No published response from Pennine Care NHS Trust was found for the earlier reports.
What recurred
- 19 Apr 2018 · Adrian Jennings · Alison Mutch · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Gareth Slater · 30 Jan 2014
“The discharge planning in relation to Mr [name redacted] was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this.”
Later · Adrian Jennings · 19 Apr 2018
“there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward;”
What happened next
No web check of the stated actions has been published for this chain.