Recurring hazard (see the quoted concerns)
Department of Health and Social Care received 2 coroners' reports about this hazard between 13 Jul 2021 and 24 Jul 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“the risk assessment requires no consideration of risk factors other than mobility unless 'Step 1' is passed regardless of the number of other risk factors”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE)”
- 2 years laterIdentical hazardConfidence 0.90 · higha different coroner
“The clinicians treating Ms [name redacted] assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessmentfactors
Department of Health and Social Care responded.Response (PDF) ↗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.
2021 → 2023Christine Nakafeero2 years after Jonathan Kingsman · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that the VTE/DVT risk assessment fails to account for important risk factors beyond mobility. This omission means patients with additional risk factors may not receive appropriate prophylaxis.
Jonathan Kingsman · 13 Jul 2021
“the risk assessment requires no consideration of risk factors other than mobility unless 'Step 1' is passed regardless of the number of other risk factors”
Original on judiciary.uk ↗ Christine Nakafeero · 24 Jul 2023
“The clinicians treating Ms [name redacted] assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE)”
Stated action
“my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE)”
No specific action could be extracted with a verified quote.
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 |
|---|---|---|---|---|
| 2021 → 2023 | 0.73 | 0.18 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
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.