Inadequate information sharing between mental health and substance misuse teams
NHS England received 2 coroners' reports about this hazard between 16 Feb 2016 and 9 Aug 2019.
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 NHS England was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“As | understand it, the question of patients giving their consent for access to RiO records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation.”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 3 years 6 months laterIdentical hazardConfidence 0.92 · higha different coroner
“(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service).”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI, including people with a 'personality disorder' and those with co-existing substance misuse. As the NHS Mental Health Implementation Plan 2019/20 - 2023/24 sets out, this new community-based offer, backed by significant investment over the next five years, will include access to psychological”
Stated timescale: 2023/24
- All reports to NHS England
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.
2016 → 2019Reece Lapina-Amarelle3 years 6 months after Philip Denning · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight inadequate information sharing between mental health services and substance misuse services.
Philip Denning · 16 Feb 2016
“As | understand it, the question of patients giving their consent for access to RiO records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation.”
Original on judiciary.uk ↗ Reece Lapina-Amarelle · 9 Aug 2019
“(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service).”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
Stated action · timescale: 2023/24
“The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI, including people with a 'personality disorder' and those with co-existing substance misuse. As the NHS Mental Health Implementation Plan 2019/20 - 2023/24 sets out, this new community-based offer, backed by significant investment over the next five years, will include access to psychological”
- 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 NHS England 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 |
|---|---|---|---|---|
| 2016 → 2019 | 0.75 | 0.14 | Identical · 0.92 | 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.