Inaccurate discharge letters to primary care
NHS England received 2 coroners' reports about this hazard between 24 Oct 2016 and 24 Jun 2019.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
First warning
Margaret Dempsie↗
24 Oct 2016 · Dianne Hocking · Leicester City and Leicestershire South
“The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs [name redacted] had been suffering from aspiration pneumonia when no pneumonia had been identified”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 2 years 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“When Mr [name redacted] was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr [name redacted] was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness”
Original on judiciary.uk ↗ Repeated from the earlier report:dischargelettercare
NHS England responded.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.
2016 → 2019Lewis Doyle2 years 8 months after Margaret Dempsie · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that hospital discharge letters to GPs contain inaccurate or omitted clinical information, risking unsafe patient care.
Margaret Dempsie · 24 Oct 2016
“The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs [name redacted] had been suffering from aspiration pneumonia when no pneumonia had been identified”
Original on judiciary.uk ↗ Lewis Doyle · 24 Jun 2019
“When Mr [name redacted] was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr [name redacted] was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness”
Original on judiciary.uk ↗
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.
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 |
|---|---|---|---|---|
| 2016 → 2019 | 0.65 | 0.16 | Closely related · 0.90 | 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.