Recurance · prevention of future deaths reports
Pre-inquest brief
Inaccessible patient information in SystmOne
The earlier warning
Simon McAndrew · 19 Feb 2014 · Dr R N Palmer, London (North)
“There are issues of poor communication which need to be addressed. I acknowledge that even the most detailed communication in this instance may not have averted Mr McAndrews' actions and subsequent death.”
judiciary.uk/prevention-of-future-death-reports/simon-mcandrew
What was promised
Stated action 1 · response to Sarah Reed (28 Jul 2017) · stated timescale: July 2017
“psychiatric reports. Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to , Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re- issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has”
Stated action 2 · response to Sarah Reed (28 Jul 2017) · stated timescale: early 2018
“The ACCT document is currently being redesigned with a view to its nationwide re- introduction in early 2018. As part of this redesign, we will consider your suggestion that a summary sheet of ACCT observations and conversations be included”
Stated action 3 · response to Sarah Reed (28 Jul 2017) · stated timescale: July 2017
“learning bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations) was issued to all prisons in July this year. The bulletin reminded staff that ACCT review meetings must be multidisciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner's management cannot attend the review, they must submit written contributions”
7 further stated actions are listed on the full chain page.
What recurred
- 28 Jul 2017 · Sarah Reed · Sir Peter Thornton QC · Closely related · confidence 0.80 (moderate)
- 21 Feb 2020 · Andrew Goldstraw · Simon Burge · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Sarah Reed · 28 Jul 2017
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'.”
Later · Andrew Goldstraw · 21 Feb 2020
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
What happened next
No web check of the stated actions has been published for this chain.