Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate nighttime patient observation documentation
The earlier warning
Neil Carter · 5 Mar 2014 · Sean Cummings, London (West)
“There were repeated failures to perform basic nursing observations”
What was promised
Stated action 1 · response to Neil Carter (5 Mar 2014) · stated timescale: none stated
“In response to points one and three, | understand that the records falsification and a number of key missing observations in Mr [name redacted] case for the afternoon he absconded from the ward, fell to one nurse, | am informed that the relevant individual was disciplined through Priory's internal processes and dismissed from employment. She was also referred to the NMC as her actions fell short of the standard required.”
What recurred
- 31 Oct 2016 · Anthony McManus · Thomas Osborne · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Neil Carter · 5 Mar 2014
“There were repeated failures to perform basic nursing observations”
Later · Anthony McManus · 31 Oct 2016
“The system of observations carried out within the unit, particularly at night is in need of reform.”
What happened next
No web check of the stated actions has been published for this chain.