Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate supervision of care coordinator role
The earlier warning
Lewis Colgan · 9 May 2018 · Crispin Butler, Buckinghamshire
“supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness.”
judiciary.uk/prevention-of-future-death-reports/lewis-colgan
What was promised
No published response from Oxford Health NHS Foundation Trust was found for the earlier reports.
What recurred
- 25 Nov 2024 · Jaipreet Panesar · Heidi Connor · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Lewis Colgan · 9 May 2018
“supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness.”
Later · Jaipreet Panesar · 25 Nov 2024
“no care co- ordinator or key worker was provided to [name redacted] after her discharge from hospital on 7th of September 2022.”
What happened next
No web check of the stated actions has been published for this chain.