Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate supervision and documentation of junior doctors
The earlier warning
Stephanie Daniels · 13 Dec 2013 · Nigel Meadows, Manchester City
“it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen.”
What was promised
Stated action 1 · response to Stephanie Daniels (13 Dec 2013) · stated timescale: none stated
“the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases.”
judiciary.uk/…/2013-0353-Response-by-Manchester-Mental-Health-N…
What recurred
- 20 Dec 2019 · Tomasz Nowasad · Nigel Meadows · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Stephanie Daniels · 13 Dec 2013
“it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen.”
Later · Tomasz Nowasad · 20 Dec 2019
“It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff”
What happened next
No web check of the stated actions has been published for this chain.