Recurance · prevention of future deaths reports
Pre-inquest brief
Fragmented mental health record keeping
The earlier warning
Kate Hedges · 3 May 2022 · Chris Morris, Manchester South
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
judiciary.uk/…/kate-hedges-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Kate Hedges (3 May 2022) · stated timescale: end of July 2022
“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”
judiciary.uk/…/2022-0130-Response-from-Greater-Manchester-Menta…
What recurred
- 2 Oct 2024 · Michael Heath · Christopher Murray · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · Kate Hedges · 3 May 2022
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
Later · Michael Heath · 2 Oct 2024
“The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.”
What happened next
No web check of the stated actions has been published for this chain.