Inadequate patient information handover between care settings
Manchester Clinical Commissioning Group received 2 coroners' reports about this hazard between 13 Dec 2013 and 8 May 2017.
They came from 1 coroner 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
Original on judiciary.uk ↗ Manchester Clinical Commissioning Group responded, stating 1 specific action.Response (PDF) ↗
“A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”
Web search (Tavily): No evidence found either way
[PDF] Serious Incident (SI) Policy ↗- 3 years 5 months laterClosely relatedConfidence 0.90 · high
“Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to Manchester Clinical Commissioning Group
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.
2013 → 2017Maud Patrick3 years 5 months after Stephanie Daniels · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight deficiencies in the handover of patient information during transfers between care settings.
Stephanie Daniels · 13 Dec 2013
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
Original on judiciary.uk ↗ Maud Patrick · 8 May 2017
“Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU.”
Original on judiciary.uk ↗
Stated action
“A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”
What happened next: No evidence found either way
The organisation has not publicly confirmed the implementation of a revised governance process or a Citywide Patient Safety Committee as described in the promise.
“Figure 3 - Role of the Patient Safety Administrative Team in SIs Datix Form Received -Review and confirm grading of Serious Incident - whether externally reportable SI -Rate incident severity with the SI Panel Review Group members SI Notification -Never Event -All Never Events are SIs -Serious Incident -Notify relevant Clinical Governance Lead, Division /Directorate Manager and appropriate Executi”
“Patient safety incident response plan Effective date: 1st May 2026 Estimated refresh date:1st May 2028 NAME TITLE SIGNATURE DATE Author [name redacted] - Patient Safety & Complaints 31/3/2026 Reviewer Dr [name redacted] Director of Clinical Governance 23/4/2026 Authoriser Sohail Munshi [name redacted] -Jamieson Joint Chief Medical Officer [name redacted]”
No evidence found does not mean the action did not happen.
No published response from Manchester Clinical Commissioning Group 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 Manchester Clinical Commissioning Group 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 |
|---|---|---|---|---|
| 2013 → 2017 | 0.74 | 0.05 | Closely related · 0.90 | 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.