Lack of national guidance on family engagement in care plans
NHS England received 2 coroners' reports about this hazard between 30 Dec 2020 and 11 Oct 2025.
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.
First warning
Steven Cooke↗
30 Dec 2020 · Emma Serrano · Stoke-on-Trent and North Staffordshire Coroner's Court
“That there is no national guidance regarding engagement with the family of a Mental Health patient”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 4 years 9 months later
Raised again · 1st time
Joanna Chamberlain↗
11 Oct 2025 · Joseph Turner · West Sussex, Brighton and Hove
Identical hazardConfidence 0.92 · higha different coroner“there is a potential need for clearer national guidance on, direction to and protocols for clinicians to proactively seek and include the views and input of family members”
Original on judiciary.uk ↗ Repeated from the earlier report:nationalguidancefamily
NHS England responded.Response (PDF) ↗
- 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.
2020 → 2025Joanna Chamberlain4 years 9 months after Steven Cooke · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight the absence of national guidance for involving families in the care of mental health patients. They call for clearer national direction to ensure family input is sought and used.
Steven Cooke · 30 Dec 2020
“That there is no national guidance regarding engagement with the family of a Mental Health patient”
Original on judiciary.uk ↗ Joanna Chamberlain · 11 Oct 2025
“there is a potential need for clearer national guidance on, direction to and protocols for clinicians to proactively seek and include the views and input of family members”
Original on judiciary.uk ↗
No published response from NHS England 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 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 |
|---|---|---|---|---|
| 2020 → 2025 | 0.80 | 0.17 | Identical · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
- Delayed referral for neurosurgical care2 reports · 2017–2026
- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
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.