Young people placed in adult mental health facilities
Department of Health and Social Care received 2 coroners' reports about this hazard between 7 Dec 2016 and 9 Nov 2017.
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 Department of Health and Social Care was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“[the deceased] was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“Placement of an under 18 year old in a Crisis house for adults”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“SC NHS FT will work with local commissioners on the benchmarking exercise”
“the NHS in Sheffield has taken a number of measures to address the concerns raised. This includes training for staff on transitions; the opening of a Section 136 suite at Sheffield Children's Hospital; and the employment of a Mental Health Liaison Consultant to commence in January 2018. In addition, an information sharing agreement is to be drawn up between NHS organisations in Sheffield.”
Stated timescale: January 2018
- All reports to Department of Health and Social Care
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.
2016 → 2017Daisy French11 months after Dominic Travis · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight the inappropriate placement of young people (under‑18 or just‑turned‑18) in adult mental health facilities where their specific needs are not met. The earlier case concerns an 18‑year‑old placed on an adult acute psychiatric ward; the later case concerns an under‑18 placed in an adult crisis house.
Dominic Travis · 7 Dec 2016
“[the deceased] was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-”
Original on judiciary.uk ↗ Daisy French · 9 Nov 2017
“Placement of an under 18 year old in a Crisis house for adults”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
Stated action
“SC NHS FT will work with local commissioners on the benchmarking exercise”
Stated action · timescale: January 2018
“the NHS in Sheffield has taken a number of measures to address the concerns raised. This includes training for staff on transitions; the opening of a Section 136 suite at Sheffield Children's Hospital; and the employment of a Mental Health Liaison Consultant to commence in January 2018. In addition, an information sharing agreement is to be drawn up between NHS organisations in Sheffield.”
- 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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2016 → 2017 | 0.66 | 0.27 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
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.