Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists received 4 coroners' reports about this hazard between 30 Apr 2014 and 15 Mar 2024.
They came from 4 different coroners in 4 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 3 of the 3 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Communication/contact between transferring establishments - there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors”
Original on judiciary.uk ↗ Royal College of Psychiatrists responded.Response (PDF) ↗
- 3 years 2 months later
“That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr [name redacted] by the private and NHS mental health services.”
Original on judiciary.uk ↗ Royal College of Psychiatrists responded, stating 1 specific action.Response (PDF) ↗
“The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”
Stated timescale: 2nd November 2017
- 5 years 10 months laterClosely relatedConfidence 0.86 · higha different coroner
“Details of her consultations and treatments were not made readily available to those working in the NHS Trusts.”
Original on judiciary.uk ↗ Royal College of Psychiatrists responded, stating 1 specific action.Response (PDF) ↗
“The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.”
Stated timescale: 2025
- 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.”
Original on judiciary.uk ↗ Repeated from the earlier report:privatementalhealthcare
Royal College of Psychiatrists responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Royal College of Psychiatrists
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.
2014 → 2023Caroline Forte9 years after Samiyo Farah · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight a lack of formal communication pathways for sharing patient information between private psychiatric providers and NHS services.
Samiyo Farah · 30 Apr 2014
“there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom)”
Original on judiciary.uk ↗ Caroline Forte · 27 Apr 2023
“Details of her consultations and treatments were not made readily available to those working in the NHS Trusts.”
Original on judiciary.uk ↗ 2017 → 2024Sarah Sutherland6 years 9 months after Jonathan Zucker · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the absence of effective coordination mechanisms between NHS and private mental health services. The earlier report focuses on missing lead clinician oversight, while the later report notes a national lack of formal or informal liaison processes.
Jonathan Zucker · 26 Jun 2017
“That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr [name redacted] by the private and NHS mental health services.”
Original on judiciary.uk ↗ Sarah Sutherland · 15 Mar 2024
“However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”
2014 → 2024Sarah Sutherland9 years 10 months after Samiyo Farah · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight the absence of formal policies or mechanisms for communication and coordination between NHS and private mental‑health providers. They describe the same hazard—lack of structured liaison—though the earlier report focuses on patient transfers while the later report concerns ongoing treatment coordination.
Samiyo Farah · 30 Apr 2014
“Communication/contact between transferring establishments - there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors”
Original on judiciary.uk ↗ Sarah Sutherland · 15 Mar 2024
“there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action · timescale: 2nd November 2017
“The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”
Stated action · timescale: 2025
“The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.”
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 Royal College of Psychiatrists 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 |
|---|---|---|---|---|
| 2014 → 2023 | 0.68 | 0.03 | Closely related · 0.86 | different |
| 2017 → 2024 | 0.73 | 0.16 | Closely related · 0.90 | different |
| 2014 → 2024 | 0.71 | 0.07 | Closely related · 0.86 | 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.