Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Kerry Hunter · 23 Apr 2019 · Nigel Parsley, Suffolk
“Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree”
judiciary.uk/prevention-of-future-death-reports/kerry-hunter
What was promised
Stated action 1 · response to Kerry Hunter (23 Apr 2019) · stated timescale: none stated
“The plan for the new Personality Disorder Service involves eight elements: 1. Clinically-led personality disorder leadership team supporting a change in culture and clinical practice at a senior level modelling consistency, accountability and leadership.”
judiciary.uk/…/2019-0137-Response-by-Norfolk-and-Suffolk-NHS-Tr…
Stated action 2 · response to Kerry Hunter (23 Apr 2019) · stated timescale: none stated
“2. Improved access and assessment that involves a needs-based screening process which works alongside diagnostic criteria to ensure people access the part of the pathway which will deliver the most benefit and prevent unnecessary admissions to hospital.”
judiciary.uk/…/2019-0137-Response-by-Norfolk-and-Suffolk-NHS-Tr…
Stated action 3 · response to Kerry Hunter (23 Apr 2019) · stated timescale: none stated
“STORM training includes specific training on safety planning, and our Dialog+ care planning tool is used to collaboratively create a safety plan for every adult and working age adult under our care. Our Youth teams have formed their own safety planning documentation which is co-produced with our young service users.”
judiciary.uk/…/2019-0137-Response-from-Norfolk-and-Suffolk-NHS-…
9 further stated actions are listed on the full chain page.
What recurred
- 28 Mar 2024 · Ellen Woolnough · Darren Stewart · Closely related · confidence 0.70 (moderate)
The clearest link, quoted from both reports:
Earlier · Kerry Hunter · 23 Apr 2019
“Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree”
Later · Ellen Woolnough · 28 Mar 2024
“The adequacy of Norfolk and Suffolk NHS Foundation Trust's (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred.”
What happened next
No evidence found either way · a stated action in a response
“Clinical Risk Assessment and Management Policy Services Applicable Trustwide x Mental Health and LD Community Health Services Version number : 5.0 Consultation Groups The Quality Committee membership and staff involved in complaint investigation and handling Approved by (Sponsor Group) The Quality Committee Ratified by: The Quality Committee Date ratified: 14th October 2020 Name of originator/aut”
[PDF] Clinical Risk Assessment and Management Policy · elft.nhs.uk/…/4499_appendix_3_-_clinical_risk_assessment_and_ma…
No evidence found does not mean the action did not happen.