Inadequate record keeping compromising patient safety
Pennine Care NHS Trust received 3 coroners' reports about this hazard between 18 Mar 2014 and 26 Jul 2018.
They came from 2 different coroners. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded.Response (PDF) ↗
- 1 year 11 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Poor record keeping, predominantly on the part of the nursing staff.”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeeping
Pennine Care NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”
- 2 years 5 months laterClosely relatedConfidence 0.90 · high
“There was evidence to show that record keeping was poor and at some points non-existent.”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeepingpoor
The most recent report. A response may not be due or published yet.
- All reports to Pennine Care NHS 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 → 2016Susan George1 year 11 months after David Chatburn · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight deficiencies in record keeping that undermine the accuracy and reliability of patient information. The earlier report focuses on GP recollection lacking contemporaneous notes, while the later report points to inadequate records kept by nursing staff.
David Chatburn · 18 Mar 2014
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
Original on judiciary.uk ↗ Susan George · 29 Feb 2016
“Poor record keeping, predominantly on the part of the nursing staff.”
Original on judiciary.uk ↗ 2016 → 2018Astonn Mitchell-Male2 years 5 months after Susan George · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify poor record keeping as a safety concern affecting patient care.
Susan George · 29 Feb 2016
“Poor record keeping, predominantly on the part of the nursing staff.”
Original on judiciary.uk ↗ Astonn Mitchell-Male · 26 Jul 2018
“There was evidence to show that record keeping was poor and at some points non-existent.”
Original on judiciary.uk ↗ 2014 → 2018Astonn Mitchell-Male4 years 4 months after David Chatburn · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight inadequate record keeping as a safety concern. The earlier report notes lack of contemporaneous records affecting accuracy, while the later report describes poor or missing records compromising patient safety.
David Chatburn · 18 Mar 2014
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
Original on judiciary.uk ↗ Astonn Mitchell-Male · 26 Jul 2018
“There was evidence to show that record keeping was poor and at some points non-existent.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action
“The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”
No published response from Pennine Care NHS 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 Pennine Care NHS 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 → 2016 | 0.70 | 0.33 | Closely related · 0.80 | different |
| 2016 → 2018 | 0.81 | 0.38 | Closely related · 0.90 | same |
| 2014 → 2018 | 0.69 | 0.22 | Identical · 0.90 | 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.