Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Elaine Jobe · 14 Jul 2014 · Dr Elizabeth Earland, Exeter & Great Devon
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
What was promised
Stated action 1 · response to Elaine Jobe (14 Jul 2014) · stated timescale: January 2015
“The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”
judiciary.uk/…/2014-0350-Response-by-Devon-Partnership-NHS-Trus…
Stated action 2 · response to Benjamin Popovach (23 Oct 2020) · stated timescale: none stated
“Immediate changes Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in a plan.”
judiciary.uk/…/2020-0214-Response-from-Devon-Partnership-NHS-Tr…
Stated action 3 · response to Archi Johnson (26 Jul 2022) · stated timescale: none stated
“The Trust has undertaken a Serious Incident Investigation following the death of [the deceased]; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.”
judiciary.uk/…/2022-0231-Response-from-Devon-Partnership-Trust-…
What recurred
- 23 Oct 2020 · Benjamin Popovach · Ian Arrow · Closely related · confidence 0.80 (moderate)
- 26 Jul 2022 · Archi Johnson · Alison Longhorn · Closely related · confidence 0.90 (high)
- 11 Dec 2023 · Paul Perrott · Deborah Archer · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Elaine Jobe · 14 Jul 2014
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
Later · Archi Johnson · 26 Jul 2022
“Two types of risk assessments were completed, with no system to ensure that important information is present on both;”
What happened next
No web check of the stated actions has been published for this chain.