Inadequate risk assessment documentation and undocumented risk disclosures
Ministry of Defence received 2 coroners' reports about this hazard between 20 Feb 2015 and 19 Nov 2020.
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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”
Original on judiciary.uk ↗ Ministry of Defence responded, stating 1 specific action.Response (PDF) ↗
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
- 5 years 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“His risk assessment was not up-to-date and his disclosures during April were not documented.”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessment
Ministry of Defence responded, stating 2 specific actions.Response (PDF) ↗
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated timescale: April 2021
“all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”
- All reports to Ministry of Defence
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 → 2020Paul Hills5 years 9 months after Richard Jones · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in documenting and communicating risk information about service members with mental health concerns. The earlier report focuses on recording risk level and urgency, while the later report notes an outdated risk assessment and undocumented disclosures.
Richard Jones · 20 Feb 2015
“As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”
Original on judiciary.uk ↗ Paul Hills · 19 Nov 2020
“His risk assessment was not up-to-date and his disclosures during April were not documented.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
Stated action
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
Stated action · timescale: April 2021
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated action
“all routine clinical notes should be entered directly on to the patient's electronic file, and any handwritten notes shredded after that happens”
- 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 Ministry of Defence 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 → 2020 | 0.73 | 0.04 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Ministry of Defence
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.