Delayed emergency response due to unclear call protocol
Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 19 Jan 2022 and 5 Jan 2024.
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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Delayed recognition of Mrs [name redacted] declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in”
Original on judiciary.uk ↗ Nottinghamshire Healthcare NHS Foundation Trust responded, stating 3 specific actions.Response (PDF) ↗
“the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be wom on a lanyard alongside individual identification badges, acting as an immediate within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.”
Stated timescale: mid-April 2022
“Additionally, the Division is rolling out handheld devices that allow staff to immediately enter automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Wade Unit”
Stated timescale: by end of May 2022
1 more stated action in the Promises tab.
- 2 years laterClosely relatedConfidence 0.85 · higha different coroner
“There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service.”
Original on judiciary.uk ↗ Nottinghamshire Healthcare NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”
Stated timescale: next 12 months
- All reports to Nottinghamshire Healthcare 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.
2022 → 2024Tammy Watkins2 years after Michelle Whitehead · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with summoning emergency medical help – the earlier notes a delay in calling paramedics, while the later describes confusion over who should make the call and how to relay information.
Michelle Whitehead · 19 Jan 2022
“Delayed recognition of Mrs [name redacted] declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in”
Original on judiciary.uk ↗ Tammy Watkins · 5 Jan 2024
“There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service.”
Original on judiciary.uk ↗
Stated action · timescale: mid-April 2022
“the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be wom on a lanyard alongside individual identification badges, acting as an immediate within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.”
Stated action · timescale: by end of May 2022
“Additionally, the Division is rolling out handheld devices that allow staff to immediately enter automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Wade Unit”
Stated action · timescale: 9 March 2022
“The Trust Resuscitation committee is convening (initially on 9 March 2022) to review the Rapid Tranquilisation Policy and will explore, review and determine what actions should be taken should @ patient fall asleep post rapid tranquilisation administration.”
Stated action · timescale: next 12 months
“The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”
- 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 Nottinghamshire Healthcare 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 |
|---|---|---|---|---|
| 2022 → 2024 | 0.71 | 0.10 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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- Inadequate death investigation with false statements and omitted GP requests2 reports · 2021–2024
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.