Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate death investigation with false statements and omitted GP requests
The earlier warning
Paul Barton · 14 Oct 2021 · Gordon Clow, Nottinghamshire
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern.”
judiciary.uk/…/paul-barton-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Paul Barton (14 Oct 2021) · stated timescale: 31 December 2021
“The updated procedure will be shared with all staff via email and discussed with all staff via team meetings.”
judiciary.uk/…/2021-0338-Response-from-Nottingham-Healthcare-NH…
What recurred
- 25 Mar 2024 · Alexander Lyalushko · Amanda Bewley · Closely related · confidence 0.78 (moderate)
The clearest link, quoted from both reports:
Earlier · Paul Barton · 14 Oct 2021
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern.”
Later · Alexander Lyalushko · 25 Mar 2024
“it did not identify that a request from Mr [name redacted] GP in November 2022 for involvement of its service with Mr [name redacted] had not been actioned;”
What happened next
No web check of the stated actions has been published for this chain.