Inadequate risk assessment documentation and inaccurate record keeping

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2018 → 2025Darren Turner7 years 1 month after Timothy Shaw · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight problems with the quality and reliability of clinical documentation and record‑keeping within the trust. The later report specifies concrete examples such as cut‑and‑paste errors, while the earlier report calls for general improvement in record‑keeping standards.

  Timothy Shaw · 15 Feb 2018

  “The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.”

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  Darren Turner · 17 Mar 2025

  “in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy - with evidence of the 'cutting and pasting' of entries”

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  Earlier report in the app · Later report in the app

• 2018 → 2025Julie Beasley7 years 3 months after Timothy Shaw · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight deficiencies in the standard and accuracy of record keeping by healthcare staff. The later report specifies that poor record keeping accompanied a lack of professional curiosity in assessing risk.

  Timothy Shaw · 15 Feb 2018

  “- The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.”

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  Julie Beasley · 28 May 2025

  “There was a lack of professional curiosity and poor record keeping and rationale for decision-making.”

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  Earlier report in the app · Later report in the app

• 2024 → 2025Stuart Berry1 year 4 months after Danny Anderson · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight insufficient risk formulation and discharge planning processes within the trust.

  Danny Anderson · 25 Jul 2024

  “There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”

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  Stuart Berry · 1 Dec 2025

  “including: Communication; Training & Supervision; Record Keeping; Discharge Planning; Care Planning; Risk Assessment.”

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  Earlier report in the app · Later report in the app

• 2025 → 2026Katharine Corrigan1 year 2 months after Darren Turner · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight failures to keep patients' risk assessments and care plans up‑to‑date and accurately documented.

  Darren Turner · 17 Mar 2025

  “Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to [the deceased]'s risk assessment consistent with Trust policy.”

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  Katharine Corrigan · 1 Jun 2026

  “Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”

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  Stated action in the response to the earlier report

  “The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting.”

  Earlier report in the app · Later report in the app

• 2024 → 2026Katharine Corrigan1 year 10 months after Danny Anderson · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight failures in conducting proper risk assessments and updating care plans based on patient information.

  Danny Anderson · 25 Jul 2024

  “There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”

  Check it in the source

  Katharine Corrigan · 1 Jun 2026

  “Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early waring signs and triggers”

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  Stated action in the response to the earlier report

  “The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.”

  Earlier report in the app · Later report in the app

• 2025 → 2026Katharine Corrigan6 months after Stuart Berry · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures to keep risk assessments and care plans up‑to‑date and properly documented in patients’ records. The earlier case concerns Mr [name redacted]’s outdated risk assessment; the later case concerns Ms [name redacted]’s missing early warning signs and inaccurate information.

  Stuart Berry · 1 Dec 2025

  “(c) Failures in Risk Assessments: specifically, failures to appropriately up- date and document matters relating to Mr [name redacted] risk assessment consistent with Trust policy.”

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  Katharine Corrigan · 1 Jun 2026

  “6. Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”

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  Earlier report in the app · Later report in the app

• 2025 → 2026Katharine Corrigan1 year after Julie Beasley · same coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures to keep risk assessments and care plans up to date and to document important clinical information.

  Julie Beasley · 28 May 2025

  “Multiple experienced members of the mental health teams had contact with Mrs [name redacted] between January and March and did not make detailed entries into the medical”

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  Katharine Corrigan · 1 Jun 2026

  “Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner and are supported through the MDT approach which then supports a joined up approach to patient assessments. Staff in the Mental Health Crisis team are required to undertake a mental health assessment for all patients, which is monitored and audited via supervision meetings and compliance reviews.”

  Earlier report in the app · Later report in the app