Lack of lead practitioner during transfer leading to lost follow up
Sussex Partnership NHS Trust received 3 coroners' reports about this hazard between 5 Dec 2014 and 15 Mar 2021.
They came from 2 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up”
Original on judiciary.uk ↗ Sussex Partnership NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“A further action was a review of the triage function/process to include increased involvement from Consultant [name redacted] and additional members of ATS. All clinical triage meetings have a Consultant [name redacted], lead nurse, and administrator present. Following Mr [name redacted] neues Associate Specialist has been invited to attend the triage meetings on a regular basis.”
- 5 years later
“When transferring patients between the CHRTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment.”
Original on judiciary.uk ↗ Sussex Partnership NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“Allocation of a Lead Practitioner of patients transferred from the CRHTT and ATS”
Stated timescale: 7 days
- 1 year 4 months later
Raised again · 2nd time
Timothy Steele↗
15 Mar 2021 · Veronica Hamilton-Deeley · City of Brighton and Hove
Identical hazardConfidence 0.90 · higha different coroner“Mr [name redacted] was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him.”
Original on judiciary.uk ↗ Repeated from the earlier report:LeadPractitioner
The most recent report. A response may not be due or published yet.
- All reports to Sussex Partnership 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.
2019 → 2021Timothy Steele1 year 4 months after George Rogers · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a designated Lead Practitioner when patients move between services, which can compromise care continuity.
George Rogers · 27 Nov 2019
“When transferring patients between the CHRTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment.”
Original on judiciary.uk ↗ Timothy Steele · 15 Mar 2021
“Mr [name redacted] was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him.”
Original on judiciary.uk ↗ 2014 → 2021Timothy Steele6 years 3 months after Paul Hyde · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports describe patients being lost to follow‑up because the trust lacked adequate processes to ensure contact and review.
Paul Hyde · 5 Dec 2014
“There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up”
Original on judiciary.uk ↗ Timothy Steele · 15 Mar 2021
“Mr [name redacted] was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“A further action was a review of the triage function/process to include increased involvement from Consultant [name redacted] and additional members of ATS. All clinical triage meetings have a Consultant [name redacted], lead nurse, and administrator present. Following Mr [name redacted] neues Associate Specialist has been invited to attend the triage meetings on a regular basis.”
Stated action
“A further action was a review of the triage function/process to include increased involvement from Consultant [name redacted] and additional members of ATS. All clinical triage meetings have a Consultant [name redacted], lead nurse, and administrator present. Following Mr [name redacted] neues Associate Specialist has been invited to attend the triage meetings on a regular basis.”
Stated action · timescale: 7 days
“Allocation of a Lead Practitioner of patients transferred from the CRHTT and ATS”
No published response from Sussex Partnership NHS Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Sussex Partnership 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 |
|---|---|---|---|---|
| 2019 → 2021 | 0.72 | 0.24 | Identical · 0.90 | different |
| 2014 → 2021 | 0.66 | 0.08 | Closely related · 0.80 | 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.