Lack of care plan coordination
Care Quality Commission received 2 coroners' reports about this hazard between 5 Apr 2016 and 6 Sept 2019.
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 Care Quality Commission was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“No appropriate care plan was developed by the District Nursing Service.”
Original on judiciary.uk ↗ No published response from Care Quality Commission was found for this report.
- 3 years 5 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.”
Original on judiciary.uk ↗ Repeated from the earlier report:careplan
Care Quality Commission responded.Response (PDF) ↗
- All reports to Care Quality Commission
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 → 2019Shannon Quinn3 years 5 months after Dorothy Imisson · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in developing or sharing appropriate care plans leading to compromised patient care. The earlier focuses on district nursing service planning, while the later concerns joint multidisciplinary trust care planning and coordination.
Dorothy Imisson · 5 Apr 2016
“No appropriate care plan was developed by the District Nursing Service.”
Original on judiciary.uk ↗ Shannon Quinn · 6 Sept 2019
“There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.”
Original on judiciary.uk ↗
No published response from Care Quality Commission was found for this report.
No specific action could be extracted with a verified quote.
- 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 Care Quality Commission 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 → 2019 | 0.75 | 0.13 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care Quality Commission
- Inaccurate and inconsistent care plan entries and record keeping10 reports · 2017–2026
- Ambulance handover delays at hospitals reduce availability3 reports · 2015–2026
- Non‑compliance with care plans and insufficient incident review5 reports · 2016–2026
- Inadequate repositioning and monitoring of at-risk patients2 reports · 2013–2025
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.