Overdue CPA meetings and missing discharge care plans
Oxford Health NHS Foundation Trust received 2 coroners' reports about this hazard between 9 May 2018 and 29 Mar 2021.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
No published response from Oxford Health NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these.”
Original on judiciary.uk ↗ No published response from Oxford Health NHS Foundation Trust was found for this report.
- 2 years 11 months laterClosely relatedConfidence 0.80 · moderate
“The application of the CPA policy for patients such as [the deceased] so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting.”
Original on judiciary.uk ↗ Repeated from the earlier report:careteam
Oxford Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“To focus on the role of the Care Coordinator: the expectations of the role and the interventions and engagement required in discharge planning in line with our CPA policy.”
Stated timescale: early June 2021
- All reports to Oxford Health 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.
2018 → 2021Roy Morris2 years 11 months after Lewis Colgan · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern shortcomings in implementing the Care Programme Approach (CPA) policy within the trust. They differ in focus: the earlier highlights missing alerting and scheduling processes for overdue CPA meetings, while the later stresses the need for a detailed CPA care plan at discharge.
Lewis Colgan · 9 May 2018
“There did not appear to be a robust reactive process for alerting members of the care team in relation to overdue Care Programme Approach (CPA) meetings nor a proactive approach to addressing the scheduling of these.”
Original on judiciary.uk ↗ Roy Morris · 29 Mar 2021
“The application of the CPA policy for patients such as [the deceased] so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting.”
Original on judiciary.uk ↗
No published response from Oxford Health NHS Foundation Trust was found for this report.
Stated action · timescale: early June 2021
“To focus on the role of the Care Coordinator: the expectations of the role and the interventions and engagement required in discharge planning in line with our CPA policy.”
- 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 Oxford Health 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 |
|---|---|---|---|---|
| 2018 → 2021 | 0.72 | 0.07 | Closely related · 0.80 | 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.