Inadequate foreign body management guidance
Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 5 Jan 2024 and 24 Oct 2025.
They came from 2 different coroners. 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.”
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
- 1 year 10 months later
Raised again · 1st time
Sophie Towle↗
24 Oct 2025 · Alexandra Poutney · Nottingham and Nottinghamshire
Closely relatedConfidence 0.90 · higha different coroner“I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance.”
Original on judiciary.uk ↗ Repeated from the earlier report:policyforeignclear
Nottinghamshire Healthcare NHS Foundation Trust responded.Response (PDF) ↗
- 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.
2024 → 2025Sophie Towle1 year 10 months after Tammy Watkins · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight deficiencies in the Trust's policies concerning foreign body incidents—one about ingestion, the other about insertion. They share the core issue of inadequate, non‑specific guidance for managing foreign bodies.
Tammy Watkins · 5 Jan 2024
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.”
Original on judiciary.uk ↗ Sophie Towle · 24 Oct 2025
“I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance.”
Original on judiciary.uk ↗
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”
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 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.74 | 0.21 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Nottinghamshire Healthcare NHS Foundation Trust
- Inadequate information sharing between healthcare teams2 reports · 2016–2026
- Inaccurate and poor record keeping in custody suite2 reports · 2020–2024
- Inadequate death investigation with false statements and omitted GP requests2 reports · 2021–2024
- Lack of staff awareness and audit of home leave policy2 reports · 2015–2024
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.