Premature discharge from community mental health services
Kernow Clinical Commissioning Group received 2 coroners' reports about this hazard between 7 Jun 2018 and 11 Nov 2021.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The discharge from CMHT on failing to attend two appointments.”
Original on judiciary.uk ↗ Kernow Clinical Commissioning Group responded, stating 1 specific action.Response (PDF) ↗
“To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken or alternatively to involve the police if there are concerns for the individuals welfare..”
Stated timescale: December 2018
- 3 years 5 months laterClosely relatedConfidence 0.85 · higha different coroner
“clients referred to the Trust were too easily discharged”
Original on judiciary.uk ↗ Kernow Clinical Commissioning Group responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“The Trust has engaged with partner agencies in contributing to the implementation of the systemwide Cornwall and Isle of Scilly Dual Diagnosis Strategy (Adults) 2019 to 2022.”
- All reports to Kernow Clinical Commissioning Group
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.
2018 → 2021Emma Burbury3 years 5 months after Marcus Hance · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports concern premature discharge of patients from community mental health services, particularly those with dual diagnosis. They highlight gaps in follow‑up and coordination leading to inadequate ongoing care.
Marcus Hance · 7 Jun 2018
“The discharge from CMHT on failing to attend two appointments.”
Original on judiciary.uk ↗ Emma Burbury · 11 Nov 2021
“clients referred to the Trust were too easily discharged”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken or alternatively to involve the police if there are concerns for the individuals welfare..”
Stated action · timescale: December 2018
“To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken or alternatively to involve the police if there are concerns for the individuals welfare..”
Stated action
“The Trust has engaged with partner agencies in contributing to the implementation of the systemwide Cornwall and Isle of Scilly Dual Diagnosis Strategy (Adults) 2019 to 2022.”
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 Kernow Clinical Commissioning Group 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 |
|---|---|---|---|---|
| 2018 → 2021 | 0.76 | 0.17 | Closely related · 0.85 | 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.