Delayed and incomplete nursing documentation
City Hospitals Sunderland NHS Foundation Trust received 2 coroners' reports about this hazard between 13 Mar 2014 and 24 Sept 2014.
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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
Original on judiciary.uk ↗ City Hospitals Sunderland NHS Foundation Trust responded, stating 4 specific actions.Response (PDF) ↗
“the Trust has undertaken the following actions: 1) We have reviewed the hospital information system, known as MEDITECH V6 to find a solution to prevent further risk for patients who on assessment are at risk of developing a venous thromboembolism episode (VTE). The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk. The medical staff will be required to complete the prescription for the thromboprophylaxis”
Stated timescale: end of May 2014
“2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights key indicators regarding the patient's healthcare needs, and treatment plan.”
2 more stated actions in the Promises tab.
- 6 months laterClosely relatedConfidence 0.85 · higha different coroner
“The nursing documentation was not as comprehensive as it ought to have been.”
Original on judiciary.uk ↗ Repeated from the earlier report:documentationought
The most recent report. A response may not be due or published yet.
- All reports to City Hospitals Sunderland 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.
2014 → 2014Leonard Hudson6 months after Jean James · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight shortcomings in the completeness and timeliness of nursing/clinical documentation. The earlier report notes delays due to interruptions, while the later report finds the documentation insufficiently comprehensive.
Jean James · 13 Mar 2014
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
Original on judiciary.uk ↗ Leonard Hudson · 24 Sept 2014
“The nursing documentation was not as comprehensive as it ought to have been.”
Original on judiciary.uk ↗
Stated action · timescale: end of May 2014
“the Trust has undertaken the following actions: 1) We have reviewed the hospital information system, known as MEDITECH V6 to find a solution to prevent further risk for patients who on assessment are at risk of developing a venous thromboembolism episode (VTE). The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk. The medical staff will be required to complete the prescription for the thromboprophylaxis”
Stated action
“2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights key indicators regarding the patient's healthcare needs, and treatment plan.”
Stated action
“3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.”
Stated action · timescale: autumn
“4) The Trust has a VTE policy based on NICE guidelines and we are currently reviewing the policy to encompass the technical changes made to the VTE assessment and prescribing process. We will hold a Trust wide clinical symposium in the autumn to ensure staff have the opportunity to discuss current issues regarding the management of patients at risk of VTE.”
No published response from City Hospitals Sunderland NHS Foundation Trust 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 City Hospitals Sunderland 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 |
|---|---|---|---|---|
| 2014 → 2014 | 0.63 | 0.14 | 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.