Inconsistent medication administration timing
Royal Cornwall Hospital received 2 coroners' reports about this hazard between 21 Oct 2020 and 11 Nov 2025.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
No published response from Royal Cornwall Hospital was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“'multiple' occasions when medication was given late and three occasions when it was not given at all”
Original on judiciary.uk ↗ No published response from Royal Cornwall Hospital was found for this report.
- 5 years 1 month laterClosely relatedConfidence 0.80 · moderate
“need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.”
Original on judiciary.uk ↗ Repeated from the earlier report:latemedication
Royal Cornwall Hospital responded.Response (PDF) ↗
- All reports to Royal Cornwall Hospital
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 → 2025Tracey Oldfield5 years 1 month after Raymond Woodhouse · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that patients do not receive their prescribed medication at the right time because of scheduling or admission processes. The earlier case concerned Parkinson's doses missed or delayed on a ward; the later case concerns usual medications not prescribed promptly for patients admitted late or unexpectedly.
Raymond Woodhouse · 21 Oct 2020
“'multiple' occasions when medication was given late and three occasions when it was not given at all”
Original on judiciary.uk ↗ Tracey Oldfield · 11 Nov 2025
“need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.”
Original on judiciary.uk ↗
No published response from Royal Cornwall Hospital was found for this report.
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 Royal Cornwall Hospital 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 → 2025 | 0.62 | 0.09 | Closely related · 0.80 | same |
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.