Recurance · prevention of future deaths reports
Pre-inquest brief
Risk assessment not updated with patient history
The earlier warning
Jack Portland · 21 Feb 2017 · Crispin Butler, Buckinghamshire
“they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr [name redacted] time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history”
judiciary.uk/prevention-of-future-death-reports/jack-portland
What was promised
Stated action 1 · response to Jack Portland (21 Feb 2017) · stated timescale: 48 April 2017
“The Governor, HMP Woodhill”
judiciary.uk/wp-content/uploads/2017/03/Portland-2017-0049.pdf
Stated action 2 · response to Jack Portland (21 Feb 2017) · stated timescale: 28th April 2017
“The section 17 leave form has been amended and is currently going through the Trust's governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017.”
judiciary.uk/…/2017-0049-Response-by-Oxford-Health-NHS-Trust.pdf
Stated action 3 · response to Jack Portland (21 Feb 2017) · stated timescale: 2016
“The Governor is confident that the increased focus on the training of staff on the requirements of the ACCT process, and the robust quality checks now in place, have led to a significant improvement in the quality, focus, and effectiveness of ACCT documents in supporting prisoners at risk of suicide and self-harm.”
What recurred
- 10 Jan 2025 · Jan Raciborski · Robert Simpson · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Jack Portland · 21 Feb 2017
“they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr [name redacted] time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history”
Later · Jan Raciborski · 10 Jan 2025
“None of the records of contact with Mr [name redacted] completed by the AMHT in the period from August 2023 to the date of Mr [name redacted] death contained any written record of a risk assessment”
What happened next
No web check of the stated actions has been published for this chain.