Lack of contingency planning for patient departure
Camden and Islington NHS Foundation Trust received 2 coroners' reports about this hazard between 12 Nov 2015 and 23 Oct 2017.
They came from 1 coroner. 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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
Original on judiciary.uk ↗ Camden and Islington NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
- 1 year 11 months laterClosely relatedConfidence 0.85 · high
“One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms [name redacted] took any leave. However, this was an unenforceable plan, because Highbury Grove is an open facility.”
Original on judiciary.uk ↗ Repeated from the earlier report:assessmentleave
Camden and Islington NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”
Stated timescale: early 2018
- All reports to Camden and Islington NHS Foundation Trust
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.
2015 → 2017Sian Witheridge1 year 11 months after Matthew Groom · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures to ensure safe management when a patient decides to leave a mental health setting. They share the concern that existing plans or assessments were not enforceable or actionable to prevent absconding.
Matthew Groom · 12 Nov 2015
“The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist.”
Original on judiciary.uk ↗ Sian Witheridge · 23 Oct 2017
“One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms [name redacted] took any leave. However, this was an unenforceable plan, because Highbury Grove is an open facility.”
Original on judiciary.uk ↗
Stated action
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Stated action
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Stated action · timescale: early 2018
“we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”
- 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 Camden and Islington NHS Foundation Trust 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 |
|---|---|---|---|---|
| 2015 → 2017 | 0.67 | 0.06 | Closely related · 0.85 | same |
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.