Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate discharge planning processes
The earlier warning
Emma Butler · 12 Apr 2019 · Crispin Butler, Buckinghamshire
“Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community.”
What was promised
Stated action 1 · response to Emma Butler (12 Apr 2019) · stated timescale: September 2019
“The Trust is considering if plastic spoons can be replaced by an alternative product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is working with the matrons to identify if there is alternative cutlery available that may be more suitable for this patient group.”
judiciary.uk/…/2019-0133-Response-by-Oxford-Health-NHS-Trust.pdf
What recurred
- 5 Jun 2025 · Cain Donald · Nicholas Graham · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Emma Butler · 12 Apr 2019
“Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community.”
Later · Cain Donald · 5 Jun 2025
“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.”
What happened next
No web check of the stated actions has been published for this chain.