Lack of formal mental health act assessment
Norfolk and Suffolk NHS Foundation Trust received 2 coroners' reports about this hazard between 9 Apr 2019 and 12 Dec 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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Formal mental health act assessment”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 5 specific actions.Response (PDF) ↗
“Daily visits from the mental health team”
“The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews”
3 more stated actions in the Promises tab.
- 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“no-one appeared to have looked at his mental health except to note that he was alcohol dependant”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealth
The most recent report. A response may not be due or published yet.
- All reports to Norfolk and Suffolk 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.
2019 → 2019Peter Frosdick8 months after Anthony Buckingham · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures to adequately assess or address the individual's mental health needs. The earlier report focuses on the absence of a formal Mental Health Act assessment, while the later report notes that no mental health evaluation was performed beyond noting alcohol dependence.
Anthony Buckingham · 9 Apr 2019
“Formal mental health act assessment”
Original on judiciary.uk ↗ Peter Frosdick · 12 Dec 2019
“no-one appeared to have looked at his mental health except to note that he was alcohol dependant”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Daily visits from the mental health team”
Stated action
“Daily visits from the mental health team”
Stated action
“The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews”
Stated action
“The report doesn't identify at which stage of care a request for a mental health act assessment may have been appropriate”
Stated action
“The team's current working process is to allocate an individual staff member to each service user; they have some additional responsibilities to ensure the care package is comprehensive and includes all other agencies”
Stated action
“Thinking of this wider partner network and the requirement for close working, our suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides”
No published response from Norfolk and Suffolk NHS Foundation Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Norfolk and Suffolk 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 |
|---|---|---|---|---|
| 2019 → 2019 | 0.76 | 0.14 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Norfolk and Suffolk NHS Foundation Trust
- Physical health check delays mental health referrals5 reports · 2014–2024
- Restricted access to treatment for borderline personality disorder2 reports · 2019–2024
- Inconsistent medication quantity documentation and unrecorded stock2 reports · 2017–2022
- Staff unawareness of observation requirements2 reports · 2015–2022
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.