Jan Raciborski
10 Jan 2025 · Coroner Robert Simpson · Berkshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of written risk assessment
“None of the records of contact with Mr [name redacted] completed by the AMHT in the period from August 2023 to the date of Mr [name redacted] death contained any written record of a risk assessment”
2. inadequate risk assessment documentation
“failure to properly record the details of a risk assessment can lead to inadequate information sharing and the possibility of someone who relies upon the records gaining the wrong impression”
3. inability to investigate risk assessment adequacy
“does not allow the adequacy of the risk assessments to be properly investigated and could hinder investigations into deaths”
4. missed future risk identification
“a matter giving rise to a risk to life may not be identified in future investigations”
Linked reports
Closely relatedConfidence 0.92 · high
Earlier report
“they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr [name redacted] time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history”
This report
“None of the records of contact with Mr [name redacted] completed by the AMHT in the period from August 2023 to the date of Mr [name redacted] death contained any written record of a risk assessment”
Responses
2025-0018-Response-from-Oxford-Health.pdf ↗· Oxford Health NHS Foundation Trust
Stated action
“and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire”