Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of continuity of care due to excessive care team members
The earlier warning
Barbara Mayer · 23 Mar 2015 · Jacqueline Lake, Norfolk
“Although seen regularly by the Crisis Team, Mrs [name redacted] was seen by a number of different people as a result of which no trusting relationship could be established.”
judiciary.uk/prevention-of-future-death-reports/barbara-mayer
What was promised
Stated action 1 · response to Barbara Mayer (23 Mar 2015) · stated timescale: early September
“The Trust is planning to review the functions of the CRHT over the forthcoming months. Included within this review will be how we can improve the consistency of staff engaged with the service user. | would like to provide you with an update on progress in early September.”
judiciary.uk/…/2015-0113-Response-by-Norfolk-Suffolk-NHS-Trust.…
What recurred
- 13 Mar 2019 · Tamsin Grundy · Jacqueline Lake · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Barbara Mayer · 23 Mar 2015
“Although seen regularly by the Crisis Team, Mrs [name redacted] was seen by a number of different people as a result of which no trusting relationship could be established.”
Later · Tamsin Grundy · 13 Mar 2019
“Miss [name redacted] repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team.”
What happened next
No web check of the stated actions has been published for this chain.