Inadequate out-of-hours psychiatric response and unsuitable section 136 suite
NHS England received 2 coroners' reports about this hazard between 16 Feb 2024 and 23 Oct 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors”
- 8 months later
Raised again · 1st time
Declan Morrison↗
23 Oct 2024 · Simon Milburn · Cambridgeshire and Peterborough
Closely relatedConfidence 0.85 · higha different coroner“The Section 136 Suite was completely inappropriate. [the deceased]'s mental health and behaviour declined further and ultimately this resulted in his death.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
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.
2024 → 2024Declan Morrison8 months after Roberto Bottello · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that the Section 136 suite is inadequate—either due to limited out‑of‑hours resources or being wholly unsuitable for patients in crisis.
Roberto Bottello · 16 Feb 2024
“That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.”
Original on judiciary.uk ↗ Declan Morrison · 23 Oct 2024
“The Section 136 Suite was completely inappropriate. [the deceased]'s mental health and behaviour declined further and ultimately this resulted in his death.”
Original on judiciary.uk ↗
Stated action
“Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2024 | 0.64 | 0.30 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.