Incomplete investigation of patient observations
Essex Partnership University NHS Foundation Trust received 2 coroners' reports about this hazard between 19 Dec 2023 and 5 Jun 2025.
They came from 1 coroner. 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 Trust investigation was materially incomplete and there was a lost an opportunity to:”
Original on judiciary.uk ↗ Essex Partnership University NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired by the Executive Nurse and will report into the Safety of Care Committee which is chaired by the Chief Executive Officer.”
“We note that the response state at page 5 that”
- 1 year 6 months laterClosely relatedConfidence 0.85 · high
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.”
Original on judiciary.uk ↗ Repeated from the earlier report:investigationTrust
Essex Partnership University NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Essex Partnership University 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.
2023 → 2025Nicholas Gray1 year 6 months after Morgan-Rose Hart · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that the Trust's investigative processes suffered from missing or inaccurate information, leading to incomplete assessments. The earlier report cites omitted details in a death investigation, while the later report notes incorrect data in a decision‑monitoring tool.
Morgan-Rose Hart · 19 Dec 2023
“The Trust investigation was materially incomplete and there was a lost an opportunity to:”
Original on judiciary.uk ↗ Nicholas Gray · 5 Jun 2025
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired by the Executive Nurse and will report into the Safety of Care Committee which is chaired by the Chief Executive Officer.”
Stated action
“The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired by the Executive Nurse and will report into the Safety of Care Committee which is chaired by the Chief Executive Officer.”
Stated action
“We note that the response state at page 5 that”
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 Essex Partnership University 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 |
|---|---|---|---|---|
| 2023 → 2025 | 0.68 | 0.10 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Essex Partnership University NHS Foundation Trust
- Inadequate risk assessment documentation and inaccurate record keeping6 reports · 2018–2026
- Absence of mental health liaison during 72‑hour hold and missing discharge note2 reports · 2024–2025
- Lack of discharge plan responsibility and unclear care coordinator allocation2 reports · 2022–2025
- Inability to access GP medication records across systems3 reports · 2021–2025
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.