Critical clinical information lost during verbal handover
Department of Health and Social Care received 2 coroners' reports about this hazard between 10 Jul 2015 and 24 Jul 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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“When Mr [name redacted] was admitted to A & E on the 13”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 3 specific actions.Response (PDF) ↗
“the Trust has now implemented improved handover procedures between paramedics and A&E staff which should ensure that the triage nurse sees any patient notes made by the paramedics and documents this action.”
“NWAS has advised that its staff always leave a patient report form (PRF) at every hospital following a patient transfer. A copy of this form also remains with the patient following admission”
1 more stated action in the Promises tab.
- 9 years laterClosely relatedConfidence 0.85 · higha different coroner
“Evidence heard that the handover system in [the deceased]'s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2015 → 2024Regan Smith9 years after Colin Moulton · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that reliance on verbal handover without reliable documentation or system compatibility can cause critical clinical information to be lost. The earlier case concerned general patient details; the later case involved a specific abnormal blood glucose reading.
Colin Moulton · 10 Jul 2015
“When Mr [name redacted] was admitted to A & E on the 13”
Original on judiciary.uk ↗ Regan Smith · 24 Jul 2024
“Evidence heard that the handover system in [the deceased]'s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover.”
Original on judiciary.uk ↗
Stated action
“the Trust has now implemented improved handover procedures between paramedics and A&E staff which should ensure that the triage nurse sees any patient notes made by the paramedics and documents this action.”
Stated action
“NWAS has advised that its staff always leave a patient report form (PRF) at every hospital following a patient transfer. A copy of this form also remains with the patient following admission”
Stated action
“FGH has very specific patient handover procedures which require NWAS to leave a copy of the PRF with the hospital receptionist for placing with hospital documentation which is subsequently passed to the triage nurse once the patient has been booked in”
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2015 → 2024 | 0.78 | 0.17 | 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.