Poor record keeping in missing person investigations
Department of Health and Social Care received 3 coroners' reports about this hazard between 19 Jul 2017 and 21 Jul 2022.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“the standard of record keeping by both doctors and nurses was poor.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the Trust has agreed that all patients will be reviewed daily by the medical team and that the Trust is currently looking to ensure that all trauma patients with severe systemic illness will be reviewed daily by a medical doctor. This will be monitored through Trust audits.”
- 1 year 4 months laterIdentical hazardConfidence 0.95 · higha different coroner
“During the hearing it was noted that on a number of occasions record keeping was poor.”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeepingpoor
Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated timescale: 8 January 2019
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
- 3 years 8 months laterIdentical hazardConfidence 0.90 · higha different coroner
“there was evidence of poor record keeping, including records not being made, or when they were made not beinq sufficiently detailed and records beinq 3 retrospectively made and changed without the records being clearly marked that the entries were retrospective”
Original on judiciary.uk ↗ Repeated from the earlier report:poorrecordkeeping
Department of Health and Social Care responded.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.
2017 → 2018Thomas Jackson1 year 4 months after Edith Robinson · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight poor record keeping by clinical staff as a safety concern. They describe the same hazard affecting continuity of care and patient safety.
Edith Robinson · 19 Jul 2017
“the standard of record keeping by both doctors and nurses was poor.”
Original on judiciary.uk ↗ Thomas Jackson · 13 Nov 2018
“During the hearing it was noted that on a number of occasions record keeping was poor.”
Original on judiciary.uk ↗ 2018 → 2022Gaia Pope-Sutherland3 years 8 months after Thomas Jackson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight problems with poor record keeping that can impede continuity of care and lead to missed information.
Thomas Jackson · 13 Nov 2018
“During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed.”
Original on judiciary.uk ↗ Gaia Pope-Sutherland · 21 Jul 2022
“there was evidence of poor record keeping, including records not being made, or when they were made not beinq sufficiently detailed and records beinq 3 retrospectively made and changed without the records being clearly marked that the entries were retrospective”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated action
“the Trust has agreed that all patients will be reviewed daily by the medical team and that the Trust is currently looking to ensure that all trauma patients with severe systemic illness will be reviewed daily by a medical doctor. This will be monitored through Trust audits.”
Stated action · timescale: 8 January 2019
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated action
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
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 |
|---|---|---|---|---|
| 2017 → 2018 | 0.81 | 0.37 | Identical · 0.95 | different |
| 2018 → 2022 | 0.74 | 0.24 | Identical · 0.90 | 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.