Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed patient location despite police assistance
The earlier warning
Kirsty Pritchard · 17 Oct 2014 · Zafar Siddique, Black Country
“there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm”
judiciary.uk/prevention-of-future-death-reports/kirsty-pritchard
What was promised
Stated action 1 · response to Kirsty Pritchard (17 Oct 2014) · stated timescale: April 2015
“The Trust processes, including the function and service provided by CHTT, are currently under review as part of a wider mental health strategy review. This is taking place in order to modernise services, improve quality of care and access to services. This review will also ensure a seamless service across both the adult and older adult population. The plan is to implement agreed changes to the current system by April 2015.”
judiciary.uk/…/2014-0565-Response-by-Black-County-NHS-Trust_Red…
What recurred
- 12 Jul 2019 · David Jukes · Emma Brown · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Kirsty Pritchard · 17 Oct 2014
“there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm”
Later · David Jukes · 12 Jul 2019
“Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT's only recorded attempt to contact Mr. [name redacted] before the 9th October 2018 was a single call”
What happened next
No web check of the stated actions has been published for this chain.