Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate multidisciplinary team meetings
The earlier warning
Thomas Jackson · 13 Nov 2018 · Andrew Haigh, Staffordshire (South)
“It is apparent that patients do benefit from regular 'ward rounds' or 'multi- disciplinary team meetings' (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings.”
judiciary.uk/prevention-of-future-death-reports/thomas-jackson
What was promised
Stated action 1 · response to Thomas Jackson (13 Nov 2018) · stated timescale: 8 January 2019
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated action 2 · response to Thomas Jackson (13 Nov 2018) · stated timescale: none stated
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
What recurred
- 22 Feb 2024 · Jamie Pilkington · Andrew Barkley · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Thomas Jackson · 13 Nov 2018
“It is apparent that patients do benefit from regular 'ward rounds' or 'multi- disciplinary team meetings' (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings.”
Later · Jamie Pilkington · 22 Feb 2024
“There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.”
What happened next
No evidence found either way · a stated action in a response
“Patient safety incident response plan Summary This plan describes how the trust will respond to patient safety incidents, in accordance with the Patient Safety Incident Response Framework (PSIRF) and national reporting requirements.”
Patient safety incident response plan 2026 · moorfields.nhs.uk/…/patient-safety-incident-response-plan-versi…
No evidence found does not mean the action did not happen.