Missing admission risk assessments and care plan details
Avon and Wiltshire Mental Health NHS Trust received 2 coroners' reports about this hazard between 24 Jul 2015 and 14 Sept 2018.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“(1) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate.”
Original on judiciary.uk ↗ Avon and Wiltshire Mental Health NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.”
Stated timescale: 3 months
- 3 years 2 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information.”
Original on judiciary.uk ↗ Avon and Wiltshire Mental Health NHS Trust responded.Response (PDF) ↗
- All reports to Avon and Wiltshire Mental Health 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.
2015 → 2018Terence Bennett3 years 2 months after Simon Reynolds · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight shortcomings in documenting and using risk-related information for service users. The earlier report notes missing admission risk assessments, while the later report finds care and crisis plans lacking sufficient detail.
Simon Reynolds · 24 Jul 2015
“(1) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate.”
Original on judiciary.uk ↗ Terence Bennett · 14 Sept 2018
“1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.”
Stated action · timescale: 3 months
“The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.”
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 Avon and Wiltshire Mental Health 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 |
|---|---|---|---|---|
| 2015 → 2018 | 0.71 | 0.00 | Closely related · 0.80 | 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.