Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate risk information sharing and documentation
The earlier warning
Richard Jones · 20 Feb 2015 · Ian Singleton, Wiltshire & Swindon
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
judiciary.uk/prevention-of-future-death-reports/richard-jones
What was promised
Stated action 1 · response to Richard Jones (20 Feb 2015) · stated timescale: none stated
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
judiciary.uk/…/2015-0068-Response-by-Ministry-of-Defence.pdf
What recurred
- 29 Nov 2024 · Charlie Owen · Robert Simpson · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Richard Jones · 20 Feb 2015
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
Later · Charlie Owen · 29 Nov 2024
“The lack of detail contained within the case conference notes hindered this inquest's ability to establish precisely what risk information was shared.”
What happened next
No web check of the stated actions has been published for this chain.