Incomplete risk assessment before discharge
North East London Foundation Trust received 4 coroners' reports about this hazard between 6 Mar 2023 and 23 May 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 3 of the 3 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“When [the deceased] was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.”
Original on judiciary.uk ↗ North East London Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“We have detailed the actions which we will take, within the attached action plan, for your kind consideration”
- 1 month later
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
Original on judiciary.uk ↗ North East London Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“we attach a detailed action plan addressing the concerns raised by you.”
- 1 year 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“The medical record documentation for Mr [name redacted] had significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted]”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessment2022
North East London Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.”
Stated timescale: 2024-11-03
- 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“There was no robust risk assessment carried out by the Mental Health and Wellness team.”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessmentteam
North East London Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“and carers. The Mental Health and Wellness team are now using the DIALOG tool in working with patients who are presenting to services. This is a quality of life and outcome measure that is completed by service users, allowing them to focus care planning work on the most important areas of their life to them across a number of domains, including mental and physical health, relationships, and accommodation. Staff use the DIALOG questionnaire to understand what matters most to the service user and this”
Stated timescale: 2025
- 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.
2023 → 2024James Agius1 year 6 months after Carol Robinson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a missing or incomplete risk assessment before a patient’s transition from the Home Treatment Team. The earlier case concerns discharge to GP care, while the later case concerns transfer after crisis intervention.
Carol Robinson · 30 Mar 2023
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
Original on judiciary.uk ↗ James Agius · 7 Oct 2024
“The medical record documentation for Mr [name redacted] had significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted]”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we attach a detailed action plan addressing the concerns raised by you.”
2023 → 2024James Agius1 year 7 months after Evelina Vilkiene · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight missing or incomplete risk assessments during patient transfers between teams.
Evelina Vilkiene · 6 Mar 2023
“When [the deceased] was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.”
Original on judiciary.uk ↗ James Agius · 7 Oct 2024
“significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted] following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr [name redacted] attempted to take his own life”
Original on judiciary.uk ↗ 2024 → 2025George Fraser7 months after James Agius · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight deficiencies in conducting adequate risk assessments for patients under mental health care. The earlier case involved an incomplete assessment for Mr [name redacted], while the later case notes a lack of robust risk assessment by the Mental Health and Wellness team.
James Agius · 7 Oct 2024
“significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted] following his transfer following crisis intervention with the Home Treat Team”
Original on judiciary.uk ↗ George Fraser · 23 May 2025
“There was no robust risk assessment carried out by the Mental Health and Wellness team.”
Original on judiciary.uk ↗
Stated action
“We have detailed the actions which we will take, within the attached action plan, for your kind consideration”
Stated action
“we attach a detailed action plan addressing the concerns raised by you.”
Stated action · timescale: 2024-11-03
“The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.”
Stated action · timescale: 2025
“and carers. The Mental Health and Wellness team are now using the DIALOG tool in working with patients who are presenting to services. This is a quality of life and outcome measure that is completed by service users, allowing them to focus care planning work on the most important areas of their life to them across a number of domains, including mental and physical health, relationships, and accommodation. Staff use the DIALOG questionnaire to understand what matters most to the service user and this”
- 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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.78 | 0.07 | Closely related · 0.90 | different |
| 2023 → 2024 | 0.76 | 0.08 | Closely related · 0.85 | different |
| 2024 → 2025 | 0.77 | 0.05 | Closely related · 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.