Recurring hazard (see the quoted concerns)
Cornwall Council received 2 coroners' reports about this hazard between 14 May 2024 and 29 May 2025.
They came from 1 coroner 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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“A failure to advise [the deceased], as Nearest Relative, of her statutory right to request [REDACTED] assessment under the MHA.”
Original on judiciary.uk ↗ Cornwall Council responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The ICB has taken this matter seriously and the executive leadership of the ICB were presented with a paper in a formal executive group meeting. The paper provided an analysis of this issue and a proposal for how it should be addressed. The meeting took place on the 8 July 2024 and supported the proposal; which is described in this letter.”
Stated timescale: 8 July 2024
“We are continuing to work with colleagues through the Domestic Homicide Review process to identify actions stemming from the Senior Coroner's proposed recommendations.”
Stated timescale: next 6 months
- 1 year later
Raised again · 1st time
Callum Hargreaves (5)↗
29 May 2025 · Andrew Cox · Cornwall and Isles of Scilly
Closely relatedConfidence 0.85 · high“The Nearest Relative details on the MH 1 form were not completed.”
Original on judiciary.uk ↗ Repeated from the earlier report:NearestRelative
Cornwall Council responded.Response (PDF) ↗
- All reports to Cornwall Council
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.
2024 → 2025Callum Hargreaves (5)1 year after Sally Poynton · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures concerning the proper handling of nearest relative information during mental health assessments.
Sally Poynton · 14 May 2024
“A failure to advise [the deceased], as Nearest Relative, of her statutory right to request [REDACTED] assessment under the MHA.”
Original on judiciary.uk ↗ Callum Hargreaves (5) · 29 May 2025
“The Nearest Relative details on the MH 1 form were not completed.”
Original on judiciary.uk ↗
Stated action · timescale: 8 July 2024
“The ICB has taken this matter seriously and the executive leadership of the ICB were presented with a paper in a formal executive group meeting. The paper provided an analysis of this issue and a proposal for how it should be addressed. The meeting took place on the 8 July 2024 and supported the proposal; which is described in this letter.”
Stated action · timescale: next 6 months
“We are continuing to work with colleagues through the Domestic Homicide Review process to identify actions stemming from the Senior Coroner's proposed recommendations.”
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 Cornwall Council 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.67 | 0.31 | Closely related · 0.85 | 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.