Lack of strategic governance hindering incident identification
Barts Health NHS Trust received 2 coroners' reports about this hazard between 8 Sept 2023 and 12 May 2025.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It is clear that there was no strategic plan or collaboration in governance processes.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”
Stated timescale: April 2024
- 1 year 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust acknowledge that Mr [name redacted] family raised serious concerns in their family statement about the care provided to Mr [name redacted] during his final admission to Whipps Cross Hospital. The family concerns were investigated and responded to via the complaints process. The Trust recognise that provision of the complaint response 2 days before the inquest was unacceptable.”
Stated timescale: 2 days before the inquest
- All reports to Barts Health NHS 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.
2023 → 2025Kenneth Foster1 year 8 months after Lynsey Smalley · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight governance shortcomings within the organisation that hinder effective incident identification and learning. The earlier report cites a lack of strategic planning and collaboration in governance processes, while the later report points to a governance failure that prevented a case from being flagged for investigation.
Lynsey Smalley · 8 Sept 2023
“It is clear that there was no strategic plan or collaboration in governance processes.”
Original on judiciary.uk ↗ Kenneth Foster · 12 May 2025
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”
Stated action · timescale: April 2024
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”
Stated action · timescale: 2 days before the inquest
“The Trust acknowledge that Mr [name redacted] family raised serious concerns in their family statement about the care provided to Mr [name redacted] during his final admission to Whipps Cross Hospital. The family concerns were investigated and responded to via the complaints process. The Trust recognise that provision of the complaint response 2 days before the inquest was unacceptable.”
- 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 Barts Health NHS 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 |
|---|---|---|---|---|
| 2023 → 2025 | 0.77 | 0.10 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Barts Health NHS Trust
- Lack of transport suitability assessment for changing patient conditions2 reports · 2020–2026
- Governance failure in incident identification and poor quality of clinical notes3 reports · 2023–2025
- Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED3 reports · 2024–2025
- Absence of falls care plan3 reports · 2015–2024
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.