Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Michelle Whitehead · 19 Jan 2022 · Elizabeth Didcock, Nottinghamshire
“Delayed recognition of Mrs [name redacted] declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in”
judiciary.uk/…/michelle-whitehead-prevention-of-future-deaths-r…
What was promised
Stated action 1 · response to Michelle Whitehead (19 Jan 2022) · stated timescale: mid-April 2022
“the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be wom on a lanyard alongside individual identification badges, acting as an immediate within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.”
judiciary.uk/…/2022-0016-Response-from-Nottinghamshire-Healthca…
Stated action 2 · response to Michelle Whitehead (19 Jan 2022) · stated timescale: by end of May 2022
“Additionally, the Division is rolling out handheld devices that allow staff to immediately enter automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Wade Unit”
judiciary.uk/…/2022-0016-Response-from-Nottinghamshire-Healthca…
Stated action 3 · response to Michelle Whitehead (19 Jan 2022) · stated timescale: 9 March 2022
“The Trust Resuscitation committee is convening (initially on 9 March 2022) to review the Rapid Tranquilisation Policy and will explore, review and determine what actions should be taken should @ patient fall asleep post rapid tranquilisation administration.”
judiciary.uk/…/2022-0016-Response-from-Nottinghamshire-Healthca…
What recurred
- 5 Jan 2024 · Tammy Watkins · Laurinda Bower · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Michelle Whitehead · 19 Jan 2022
“Delayed recognition of Mrs [name redacted] declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in”
Later · Tammy Watkins · 5 Jan 2024
“There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service.”
What happened next
No web check of the stated actions has been published for this chain.