Recurance · prevention of future deaths reports
Pre-inquest brief
Staff unawareness of observation requirements
The earlier warning
Christopher Higgins · 24 Dec 2015 · Jacqueline Lake, Norfolk
“It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient.”
What was promised
Stated action 1 · response to Christopher Higgins (24 Dec 2015) · stated timescale: end of March 2016
“the ' Trust has decided to fully enclose the ramp. This work has commenced and is proposed to be completed by the end of March 2016”
judiciary.uk/…/2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Tr…
Stated action 2 · response to Christopher Higgins (24 Dec 2015) · stated timescale: none stated
“The Trust is taking this matter further than the Norfolk acute hospitals instructing. managers based in Suffolk to liaise with their acute hospital colleagues as well, Each area is working to create local protocols which will be incorporated into policy.”
judiciary.uk/…/2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Tr…
What recurred
- 22 Aug 2022 · Eliot Harris · Jaqueline Lake · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Christopher Higgins · 24 Dec 2015
“It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient.”
Later · Eliot Harris · 22 Aug 2022
“Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of [the deceased] in accordance with NSFT's Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly.”
What happened next
No web check of the stated actions has been published for this chain.