Incomplete medication review due to missing medical records
NHS Wales received 2 coroners' reports about this hazard between 7 Aug 2015 and 16 Sept 2016.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from NHS Wales was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up.”
Original on judiciary.uk ↗ No published response from NHS Wales was found for this report.
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“The Health Care Professional did not have access to detainee's medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to NHS Wales
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 → 2016David Phillips1 year 1 month after Kathleen Neville · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of reliable access to medication information that prevents detection of medication errors. The earlier case cites missing hospital policy; the later case cites missing access to detainee medical records.
Kathleen Neville · 7 Aug 2015
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up.”
Original on judiciary.uk ↗ David Phillips · 16 Sept 2016
“The Health Care Professional did not have access to detainee's medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.”
Original on judiciary.uk ↗
No published response from NHS Wales was found for this report.
No published response from NHS Wales 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 NHS Wales 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 | 0.64 | 0.04 | Closely related · 0.90 | 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.