Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Margaret Stringer · 17 Jun 2022 · Tim Holloway, Blackpool and Fylde
“The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs [name redacted] risk of suicide.”
judiciary.uk/…/margaret-stringer-prevention-of-future-deaths-re…
What was promised
Stated action 1 · response to Margaret Stringer (17 Jun 2022) · stated timescale: none stated
“As per the evidence of , Nightingale's is not a secure unit and a resident with a similar history to that of Ms [name redacted] would no longer be admitted to the Home. Should there be a concern in relation to a resident who was already admitted at the home, a system of 1:1 care would be implemented which would restrict access to any items. An urgent referral would therefore be arranged for assessment of the resident and the resident would be discharged to a more suitable placement/acute hospital.”
Stated action 2 · response to Margaret Stringer (17 Jun 2022) · stated timescale: 2nd August 2022
“4. The Local Authority have reviewed the case again after receipt of the Reg 28 Report and consider that the conclusion of Dr is correct, in that there was adequate assessment and management of risk of suicide and that the placement at Nightingale was appropriate. There may be some details to correct (e.g. layout of Overview document) but having had that opportunity the Local Authority does not feel there is specific action arising from the Report of its own review of actions and procedure that”
judiciary.uk/…/2022-0187-Response-from-Adult-Community-Social-C…
Stated action 3 · response to Margaret Stringer (17 Jun 2022) · stated timescale: 15 September 2022
“BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated.”
judiciary.uk/…/2022-0187-Response-from-Blackpool-Teaching-Hospi…
What recurred
- 11 Jun 2023 · Marlene McCabe · Timothy Holloway · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Margaret Stringer · 17 Jun 2022
“The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs [name redacted] risk of suicide.”
Later · Marlene McCabe · 11 Jun 2023
“There is a residual risk of non-communication of material information pertaining to patients' mental health between healthcare providers.”
What happened next
No web check of the stated actions has been published for this chain.