Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate mental health team attendance at ACCT reviews
The earlier warning
Patryk Gladysz · 18 Jul 2025 · Priya Malhotra, Inner West London
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
judiciary.uk/…/patryk-gladysz-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Patryk Gladysz (18 Jul 2025) · stated timescale: 15 October 2025
“Staffing within the Mental Health In-reach team”
What recurred
- 24 Mar 2026 · Thomas Ruggiero (2) · Ian Potter · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Patryk Gladysz · 18 Jul 2025
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
Later · Thomas Ruggiero (2) · 24 Mar 2026
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”
What happened next
No web check of the stated actions has been published for this chain.