Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete care plan and risk assessment documentation
The earlier warning
John Walker · 21 Aug 2013 · Christopher Wilkinson, West Sussex
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
What was promised
Stated action 1 · response to John Walker (21 Aug 2013) · stated timescale: none stated
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”
judiciary.uk/…/2013-0213-Response-by-Sussex-Partnership-NHS-Fou…
What recurred
- 6 Nov 2015 · Brian Shillinglaw · Veronica Hamilton-Deeley · Closely related · confidence 0.90 (high)
- 4 Jul 2017 · Janet Muller · Penelope Schofield · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · John Walker · 21 Aug 2013
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
Later · Brian Shillinglaw · 6 Nov 2015
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
What happened next
No web check of the stated actions has been published for this chain.