Recurance · prevention of future deaths reports
Pre-inquest brief
Missing prior suicide attempt information
The earlier warning
Archi Johnson · 26 Jul 2022 · Alison Longhorn, Exeter and Greater Devon
“The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”
judiciary.uk/…/archi-johnson-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Archi Johnson (26 Jul 2022) · stated timescale: none stated
“The Trust has undertaken a Serious Incident Investigation following the death of [the deceased]; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.”
judiciary.uk/…/2022-0231-Response-from-Devon-Partnership-Trust-…
What recurred
- 11 Dec 2023 · Paul Perrott · Deborah Archer · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Archi Johnson · 26 Jul 2022
“The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”
Later · Paul Perrott · 11 Dec 2023
“At least one member of staff was unaware that [the deceased] had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose”
What happened next
No web check of the stated actions has been published for this chain.