Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Marie Zarins · 14 Aug 2023 · Isobel Thistlethwaite, Leicester City and South Leicestershire
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
judiciary.uk/…/marie-zarins-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Marie Zarins (14 Aug 2023) · stated timescale: none stated
“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”
judiciary.uk/…/2023-0290-Response-from-Leicestershire-Partnersh…
Stated action 2 · response to Marie Zarins (14 Aug 2023) · stated timescale: none stated
“The Trust was unable to contact the Locum Consultant for input into the original SI investigation due to not holding the latest contact details; the Locum Consultant was no longer contracted to work with the Trust, and they had left the country.”
judiciary.uk/…/2023-0290-Response-from-Leicestershire-Partnersh…
Stated action 3 · response to Marie Zarins (14 Aug 2023) · stated timescale: none stated
“We confirm that prior to the MDT meeting, the Locum Consultant accessed SystmOne for a period of seven minutes. We also confirm that they did not raise any concerns regarding MDT meetings with the Clinical or Medical Director.”
judiciary.uk/…/2023-0290-Response-from-Leicestershire-Partnersh…
2 further stated actions are listed on the full chain page.
What recurred
- 13 Jun 2024 · Christopher Larsen · Isobel Thistlethwaite · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Marie Zarins · 14 Aug 2023
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
Later · Christopher Larsen · 13 Jun 2024
“The Serious Incident Investigation into Mr [name redacted] death did uncover and accepted some failings in relation to the care provided to Mr [name redacted].”
What happened next
No web check of the stated actions has been published for this chain.