Lack of mental capacity assessment and risk assessment in emergency settings
Care Quality Commission received 2 coroners' reports about this hazard between 8 May 2017 and 21 Feb 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 Care Quality Commission was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU.”
Original on judiciary.uk ↗ No published response from Care Quality Commission was found for this report.
- 7 years 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will,”
Original on judiciary.uk ↗ Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Care Quality Commission
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 → 2025Paul Dunne7 years 9 months after Maud Patrick · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures to properly consider or assess a patient's mental capacity or risk status in emergency settings. The earlier report notes absent mental capacity consideration during A&E transfer, while the later report describes a mental health nurse overlooking high‑risk signs and wrongly asserting capacity precludes Mental Health Act assessment.
Maud Patrick · 8 May 2017
“There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU.”
Original on judiciary.uk ↗ Paul Dunne · 21 Feb 2025
“A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will,”
Original on judiciary.uk ↗
No published response from Care Quality Commission was found for this report.
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 Care Quality Commission 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 → 2025 | 0.76 | 0.11 | Closely related · 0.80 | 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.