Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust received 3 coroners' reports about this hazard between 12 Aug 2015 and 10 Dec 2019.
They came from 1 coroner. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed.”
Original on judiciary.uk ↗ Brighton and Sussex University Hospitals NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“We have carried out a careful review of the medical records with the appropriate personnel.”
Stated timescale: 7 November 2015
- 1 year laterClosely relatedConfidence 0.85 · high
“there were missed opportunities to escalate Mrs [name redacted] treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team”
Original on judiciary.uk ↗ Repeated from the earlier report:NEWSteam
Brighton and Sussex University Hospitals NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust has also established a specific working group entitled”
- 3 years 4 months laterIdentical hazardConfidence 0.92 · high
“(1) Once again | must write concerning the serious failings in the use of NEWS. Please see the Record of Inquest for details.”
Original on judiciary.uk ↗ Brighton and Sussex University Hospitals NHS Trust responded.Response (PDF) ↗
- All reports to Brighton and Sussex University Hospitals NHS 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 → 2016Diana Ritchie1 year after Thelma Jones · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures to act on abnormal National Early Warning Scores (NEWS) that should trigger escalation of care. The earlier case notes missing completion of scoring after a high score; the later case notes unreported raised scores that did not prompt calls to clinicians.
Thelma Jones · 12 Aug 2015
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed”
Original on judiciary.uk ↗ Diana Ritchie · 18 Aug 2016
“there were missed opportunities to escalate Mrs [name redacted] treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have carried out a careful review of the medical records with the appropriate personnel.”
2015 → 2019Frances Gibb4 years 4 months after Thelma Jones · same coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight failures to complete NEWS scoring after a patient's deterioration. They refer to the same specific hazard: incomplete use of the National Early Warning System.
Thelma Jones · 12 Aug 2015
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed.”
Original on judiciary.uk ↗ Frances Gibb · 10 Dec 2019
“(1) Once again | must write concerning the serious failings in the use of NEWS. Please see the Record of Inquest for details.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have carried out a careful review of the medical records with the appropriate personnel.”
Stated action · timescale: 7 November 2015
“We have carried out a careful review of the medical records with the appropriate personnel.”
Stated action
“The Trust has also established a specific working group entitled”
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 Brighton and Sussex University Hospitals NHS 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 → 2016 | 0.79 | 0.08 | Closely related · 0.85 | same |
| 2015 → 2019 | 0.71 | 0.11 | Identical · 0.92 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Brighton and Sussex University Hospitals NHS Trust
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.