Despite Katie Simpson being registered with the Southern Trust since birth and throughout her short life, it has decided not to declare Serious Adverse Incident (SAI) over the handling of her case, unlike Western Trust counterparts.
An SAI is an incident or event that must be reported to the Department of Health and in some cases, the Regulation and Quality Improvement Authority and investigated.
It may be a clinical incident arising from a number of factors including serious harm, unexpected or unexplained death; serious risk to wellbeing or safety, or serious self-harm or assault.
The incident or event may affect service users, members of the public or staff.
Investigations take up to 12 weeks and aim to find out what happened, why it happened and what can be done to prevent it happening again.
Last month, following publication of Dr Jan Melia’s damaging report into shocking failures from all agencies during Katie’s life, the Western Trust confirmed an SAI had been declared after she was admitted unresponsive to Altnagelvin Hospital on August 3, 2020 and where she passed away six days later.
Jonathan Creswell, who was in a relationship with Katie’s sister Christina, claimed to have rescued her from a suicide attempt when in fact she had been raped and murdered.
It tooks months for a PSNI investigation to be launched leading to Creswell’s arrest for murder.
Three years he went on trial in April 2024, which collapsed after one day when he was discovered deceased at his bail address, having taken his own life.
Suspicions were raised while Katie was in hospital including by medical staff who were promptly reminded they were ‘nurses, not police’.
There were also concerns around Creswell’s living arrangements, sharing a small house with his partner Christina, their two children, Katie and another woman, Rose de Montmorency-Wright (who became a co-defendant in the murder case), particularly given his convictions for serious violence against women.
The report revealed the house was cluttered, with just mattresses on the floor in bedrooms.
Katie’s presentation as an alleged hanging victim was also highlighted as well as her 18 previous hospital admissions for horse falls, generally accompanied by Creswell.
All these matters fell within the Western Trust and following publication of the report it was confirmed the Rapid Review Group had agreed the threshold for an SAI. was met.
However, while Katie lived in various areas including Donegal and Derry/Londonderry, her GP practice which was under the Southern Trust remit, never changed.
Regardless of where her numerous injuries were inflicted, or which hospital she was treated in, at all times she remained a Southern Trust patient.
Creswell groomed Katie from a young age, while she lived in Tynan, County Armagh, using the lure of the horses which she adored.
Concerning incidents appeared to go unnoticed such as Katie running away from home and trying to get to Scotland but prevented from traveling by ferry after being discovered as a stowaway.
This was an alarming instance which should have been reported to Social Services who may have been able to establish why Katie was running away. It was another example when Creswell’s behaviour could have been uncovered and stopped.
Following publication of the report when asked if an SAI had been declared, a spokesperson said: “The Trust will not be undertaking an SAI review but we will continue to progress the findings and recommendations from the recently published Independent Review into the tragic death of Katie Simpson. We will keep working closely with partner agencies to improve safeguarding across all services and ensure a consistent and effective approach to safeguarding.”
