Recurance · prevention of future deaths reports
Pre-inquest brief
Missing admission risk assessments and care plan details
The earlier warning
Simon Reynolds · 24 Jul 2015 · Maria Voisin, Avon
“(1) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate.”
judiciary.uk/prevention-of-future-death-reports/simon-reynolds
What was promised
Stated action 1 · response to Simon Reynolds (24 Jul 2015) · stated timescale: 3 months
“The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.”
What recurred
- 14 Sept 2018 · Terence Bennett · Nicholas Rheinberg · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Simon Reynolds · 24 Jul 2015
“(1) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate.”
Later · Terence Bennett · 14 Sept 2018
“1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information.”
What happened next
No web check of the stated actions has been published for this chain.