Inadequate discharge safety planning and communication
North East London Foundation Trust received 2 coroners' reports about this hazard between 13 Jun 2016 and 30 Mar 2023.
They came from 1 coroner 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 report also did not to any extent consider whether there was an adequate safety plan in place on discharge.”
Original on judiciary.uk ↗ North East London Foundation Trust responded.Response (PDF) ↗
- 6 years 10 months laterClosely relatedConfidence 0.85 · high
“There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team.”
Original on judiciary.uk ↗ Repeated from the earlier report:plandischarge
North East London Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“we attach a detailed action plan addressing the concerns raised by you.”
- All reports to North East London Foundation Trust
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 → 2023Carol Robinson6 years 10 months after Laura McRory · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight deficiencies in discharge planning that could compromise safety. The earlier report focuses on lacking safety plans for staff mental health discharge, while the later report notes absent multidisciplinary discussion for patient discharge safety.
Laura McRory · 13 Jun 2016
“The report also did not to any extent consider whether there was an adequate safety plan in place on discharge.”
Original on judiciary.uk ↗ Carol Robinson · 30 Mar 2023
“There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action
“we attach a detailed action plan addressing the concerns raised by you.”
- 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 North East London Foundation Trust 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 → 2023 | 0.74 | 0.08 | Closely related · 0.85 | same |
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.