Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate inter-agency communication about risk and urgency
The earlier warning
Richard Jones · 20 Feb 2015 · Ian Singleton, Wiltshire & Swindon
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
judiciary.uk/prevention-of-future-death-reports/richard-jones
What was promised
Stated action 1 · response to Richard Jones (20 Feb 2015) · stated timescale: end of April 2015
“The Ministry of Defence (MoD) has responsibility for the provision of primary care services for serving personnel. The MoD also provides additional mental health care for serving personnel delivered through fifteen military Departments of Community Mental Health (DCMHs) located in military centres in the UK, as well as centres overseas.”
judiciary.uk/…/2015-0068-Response-by-Department-of-Health2.pdf
What recurred
- 26 Apr 2021 · Alan Massam · Alison Mutch · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Richard Jones · 20 Feb 2015
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
Later · Alan Massam · 26 Apr 2021
“there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases”
What happened next
No web check of the stated actions has been published for this chain.