Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate risk assessment for self-harm patients
The earlier warning
Alexander Holt · 3 Feb 2015 · Christopher Dorries, South Yorkshire (West)
“It was accepted at the inquest that more could have been taken into account in risk assessing Mr [name redacted].”
judiciary.uk/prevention-of-future-death-reports/alexander-holt
What was promised
No published response from Sheffield Health and Social Care NHS Foundation Trust was found for the earlier reports.
What recurred
- 20 Nov 2023 · Gareth Etchells-Height · Alexandra Pountney · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Alexander Holt · 3 Feb 2015
“It was accepted at the inquest that more could have been taken into account in risk assessing Mr [name redacted].”
Later · Gareth Etchells-Height · 20 Nov 2023
“There was a failure to update [the deceased]'s risk assessment, which at the date of his death was last updated on 7 April 2022.”
What happened next
No web check of the stated actions has been published for this chain.