Incomplete or inaccurate transfer of care documentation
Betsi Cadwaladr University Health Board received 2 coroners' reports about this hazard between 20 Aug 2015 and 14 Sept 2023.
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 Betsi Cadwaladr University Health Board was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequenily found to be inaccurate.”
Original on judiciary.uk ↗ No published response from Betsi Cadwaladr University Health Board was found for this report.
- 8 years 1 month later
Raised again · 1st time
Richard Griffiths↗
14 Sept 2023 · Kate Robertson · North Wales East and Central
Closely relatedConfidence 0.80 · moderatea different coroner“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
Original on judiciary.uk ↗ Repeated from the earlier report:TransferCare
Betsi Cadwaladr University Health Board responded, stating 1 specific action.Response (PDF) ↗
“incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol”
Stated timescale: end of January 2024
- All reports to Betsi Cadwaladr University Health Board
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 → 2023Richard Griffiths8 years 1 month after Andrew Roberts · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports identify problems with the Transfer of Care documentation – its incomplete or inaccurate completion and lack of clear process. The earlier report focuses on the form not being filled out correctly, while the later report highlights missing procedural details and investigation shortcomings.
Andrew Roberts · 20 Aug 2015
“That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequenily found to be inaccurate.”
Original on judiciary.uk ↗ Richard Griffiths · 14 Sept 2023
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
Original on judiciary.uk ↗
No published response from Betsi Cadwaladr University Health Board was found for this report.
Stated action · timescale: end of January 2024
“incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol”
- 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 Betsi Cadwaladr University Health Board 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 → 2023 | 0.72 | 0.17 | 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.