Recurance · prevention of future deaths reports
Pre-inquest brief
Missed mental health observations not communicated to healthcare staff
The earlier warning
Brian Dalrymple · 18 Sept 2014 · Jeremy Chipperfield, West London
“Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.”
judiciary.uk/prevention-of-future-death-reports/brian-dalrymple
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 28 Aug 2019 · Amir Siman-Tov · Sean Cummings · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Brian Dalrymple · 18 Sept 2014
“Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.”
Later · Amir Siman-Tov · 28 Aug 2019
“A GP who had seen Mr [name redacted] during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process.”
What happened next
No web check of the stated actions has been published for this chain.