Recurring hazard (see the quoted concerns)
NHS England received 2 coroners' reports about this hazard between 16 Feb 2024 and 14 Oct 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 9 specific actions.
The story, report by report
Spacing grows with the time between reports.
“That CNWL failed in its duty of candour in relation to provision of evidence in this case.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors”
- 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“delay in fulfilling the Duty of Candour' obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice.”
Original on judiciary.uk ↗ Repeated from the earlier report:DutyCandour'
NHS England responded, stating 8 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“A recent RQR meeting with TCT has resulted in an agreed plan for them to adopt the national paediatric early warning system (PEWS).”
“TCT agreed to further their connections within the local integrated care system and with tertiary care providers to improve flow to clinical appointments.”
6 more stated actions in the Promises tab.
- All reports to NHS England
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 → 2024Mia Gauci-Lamport8 months after Roberto Bottello · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures to fulfil the duty of candour obligation. The earlier case concerns mental health service evidence provision, while the later case concerns pediatric care governance and training.
Roberto Bottello · 16 Feb 2024
“That CNWL failed in its duty of candour in relation to provision of evidence in this case.”
Original on judiciary.uk ↗ Mia Gauci-Lamport · 14 Oct 2024
“delay in fulfilling the Duty of Candour' obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice.”
Original on judiciary.uk ↗
Stated action
“Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors”
Stated action
“A recent RQR meeting with TCT has resulted in an agreed plan for them to adopt the national paediatric early warning system (PEWS).”
Stated action
“TCT agreed to further their connections within the local integrated care system and with tertiary care providers to improve flow to clinical appointments.”
Stated action
“The acute trust paediatric nursing colleagues involved in the RQR meeting were positive about the steps TCT had taken so far to review and audit observations and monitoring.”
Stated action
“Our NHS England Regional Medical Director has also offered to support with connecting TCT's clinical team to specialists within the NHS that can offer peer support and further improvement work.”
Stated action
“the CQC inform us that they are monitoring the service to ensure that children residing there are not exposed to risk or unsafe care, which is of utmost importance so deaths such as [the deceased]'s can be prevented. CQC regulates the premises and the care provided, and they are reviewing any information received to help inform the next inspection.”
Stated action
“NHSE have provided assurance that their regional team has been working with system and other partners on responding to risks and concerns in a joint approach at this provider, which will be set out in their response.”
Stated action · timescale: 26 November
“The Government is supportive of the review on the duty it inherited from the previous administration and will consider the findings, recently published on 26 November, following a call for evidence in April this year. The government will consider these findings alongside findings from the ongoing manager regulation consultation as it continues to develop policy on candour in healthcare.”
Stated action · timescale: await the outcome of Ofsted's inspection
“On 18th October 2023 CQC requested the outcome of the external investigation from the registered manager at TCT. This wasn't available, but TCT shared the findings with CQC of the internal investigation. Alongside the evidence of findings from the Ofsted inspection the CQC made the decision to await the external investigation findings before scheduling an inspection.”
- 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 England 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 → 2024 | 0.71 | 0.18 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.