Inadequate discharge medication risk assessment
Greater Manchester Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 24 Jul 2019 and 25 Sept 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Greater Manchester Mental Health NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU.”
Original on judiciary.uk ↗ No published response from Greater Manchester Mental Health NHS Foundation Trust was found for this report.
- 4 years 2 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“No medication was prescribed or dispensed to the Deceased at the time of self-discharge.”
Original on judiciary.uk ↗ Greater Manchester Mental Health NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Greater Manchester Mental Health NHS Foundation 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.
2019 → 2023Shaun Houghton4 years 2 months after Hannah Bharaj · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with medication management when a patient leaves hospital care – the earlier report cites lack of consideration of discharge medication and prescribing risk, while the later report notes that no medication was prescribed or dispensed at self‑discharge.
Hannah Bharaj · 24 Jul 2019
“There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU.”
Original on judiciary.uk ↗ Shaun Houghton · 25 Sept 2023
“No medication was prescribed or dispensed to the Deceased at the time of self-discharge.”
Original on judiciary.uk ↗
No published response from Greater Manchester Mental Health NHS Foundation Trust 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 Greater Manchester Mental Health NHS Foundation 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 |
|---|---|---|---|---|
| 2019 → 2023 | 0.77 | 0.13 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Greater Manchester Mental Health NHS Foundation Trust
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.