Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Stephanie Daniels · 13 Dec 2013 · Nigel Meadows, Manchester City
“MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”
What was promised
Stated action 1 · response to Stephanie Daniels (13 Dec 2013) · stated timescale: none stated
“I expect all healthcare professionals working in local Trusts to be fully trained and aware of the existing protocols in their local Trust. It is for local healthcare organisations to ensure that all staff are trained to the appropriate standard.”
judiciary.uk/…/2013-0353-Response-by-Department-of-Health.pdf
What recurred
- 11 Jun 2024 · Juan Martin · Priya Malhotra · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Stephanie Daniels · 13 Dec 2013
“MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”
Later · Juan Martin · 11 Jun 2024
“Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.”
What happened next
No evidence found either way · a stated action in a response
The organisation's statement describes a commitment to community-based mental health care but provides no specific timeline or implementation details.
No evidence found does not mean the action did not happen.
No evidence found either way · a stated action in a response
“Hospital bed capacity management is one of the most [critical operational challenges health systems face](/how-virtual-nursing-solves-the-top-5-nursing-challenges/) today.”
Patient Throughput & Bed Capacity Management in Hospitals · artisight.com/…/bed-capacity-management-in-hospitals-strategies…
No evidence found does not mean the action did not happen.