Outdated care plan and risk assessment
Ministry of Defence received 2 coroners' reports about this hazard between 19 Nov 2020 and 6 Dec 2021.
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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
Original on judiciary.uk ↗ Ministry of Defence responded, stating 2 specific actions.Response (PDF) ↗
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated timescale: April 2021
“all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”
- 1 year 1 month laterClosely relatedConfidence 0.78 · moderatea different coroner
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessmentcareplan
Ministry of Defence responded, stating 1 specific action.Response (PDF) ↗
“case. I will address each area in turn. Disclosure of information between DCMH and the Chain of Command. DCMH operates as an independent organisation, which sits within Defence Primary Healthcare (DPHC), a Tri-Service organisation in UK Strategic Command. Although military DCMH staff2 are drawn from the medical services of the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of all three Service chains of command. Mental health services play a vital Occupational Health role in”
- All reports to Ministry of Defence
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.
2020 → 2021Alexander Tostevin1 year 1 month after Paul Hills · different coronerClosely relatedConfidence 0.78 · moderate
Closely relatedConfidence 0.78 · moderateBoth reports highlight deficiencies in updating and integrating risk assessments and care plans for military personnel with mental health needs.
Paul Hills · 19 Nov 2020
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
Original on judiciary.uk ↗ Alexander Tostevin · 6 Dec 2021
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated action · timescale: April 2021
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated action
“all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”
Stated action
“case. I will address each area in turn. Disclosure of information between DCMH and the Chain of Command. DCMH operates as an independent organisation, which sits within Defence Primary Healthcare (DPHC), a Tri-Service organisation in UK Strategic Command. Although military DCMH staff2 are drawn from the medical services of the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of all three Service chains of command. Mental health services play a vital Occupational Health role in”
- 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 Ministry of Defence 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 |
|---|---|---|---|---|
| 2020 → 2021 | 0.73 | 0.19 | Closely related · 0.78 | 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.