Recurance · prevention of future deaths reports
Pre-inquest brief
Recurring hazard (see the quoted concerns)
The earlier warning
Jonathan Kingsman · 13 Jul 2021 · Simon Milburn, Cambridgeshire & Peterborough
“the risk assessment requires no consideration of risk factors other than mobility unless 'Step 1' is passed regardless of the number of other risk factors”
What was promised
Stated action 1 · response to Jonathan Kingsman (13 Jul 2021) · stated timescale: none stated
“my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE)”
judiciary.uk/…/2021-0238-Response-from-Department-of-Health-Soc…
What recurred
- 24 Jul 2023 · Christine Nakafeero · Graeme Irvine · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jonathan Kingsman · 13 Jul 2021
“the risk assessment requires no consideration of risk factors other than mobility unless 'Step 1' is passed regardless of the number of other risk factors”
Later · Christine Nakafeero · 24 Jul 2023
“The clinicians treating Ms [name redacted] assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors”
What happened next
No web check of the stated actions has been published for this chain.