Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of medication monitoring after clinic visit
The earlier warning
Peter Fleming · 14 Jul 2023 · James Bennett, Birmingham and Solihull
“the deceased went without his medication. The deceased's GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse's involvement.”
judiciary.uk/…/peter-fleming-prevention-of-future-deaths-report
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 4 Mar 2025 · Matthew Lynch · Louise Hunt · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Peter Fleming · 14 Jul 2023
“the deceased went without his medication. The deceased's GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse's involvement.”
Later · Matthew Lynch · 4 Mar 2025
“Internal investigation: The internal investigation did not address how and whether the offender's use of medication should have been monitored after the clinic visit on 12/05/23.”
What happened next
No web check of the stated actions has been published for this chain.