Lack of coordinated support for vulnerable adults with complex needs
Department of Health and Social Care received 2 coroners' reports about this hazard between 11 Feb 2022 and 26 Mar 2023.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“no -one saw [the deceased] as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We can also confirm that we will, going forward, ensure that we continue to work together across the Greater Manchester health and care system so that changes in practice are actioned and reviewed.”
“we are, through the development and implementation in local areas of the Community Mental Health Framework (CMHF), working to improve the way people with mental health conditions access joined-up support across health and social care”
Stated timescale: end of 2023/24
- 1 year 1 month laterClosely relatedConfidence 0.85 · higha different coroner
“She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision.”
Original on judiciary.uk ↗ Repeated from the earlier report:vulnerablecomplexneedsCare
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.
2022 → 2023Jordan Clare1 year 1 month after Matthew McManus · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight the absence of a single point of contact or coordinated care for vulnerable adults with complex mental health and social care needs. They differ in that the earlier report concerns a specific individual case, while the later report describes a systemic gap across many local authorities.
Matthew McManus · 11 Feb 2022
“no -one saw [the deceased] as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.”
Original on judiciary.uk ↗ Jordan Clare · 26 Mar 2023
“She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision.”
Original on judiciary.uk ↗
Stated action
“We can also confirm that we will, going forward, ensure that we continue to work together across the Greater Manchester health and care system so that changes in practice are actioned and reviewed.”
Stated action · timescale: end of 2023/24
“we are, through the development and implementation in local areas of the Community Mental Health Framework (CMHF), working to improve the way people with mental health conditions access joined-up support across health and social care”
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 |
|---|---|---|---|---|
| 2022 → 2023 | 0.80 | 0.33 | 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.