Inadequate family involvement in care
Department of Health and Social Care received 2 coroners' reports about this hazard between 3 Oct 2016 and 16 Aug 2019.
They came from 2 different coroners. 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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK. website at the following address: https://www.gov.uk/government/publications/assessing-and-managing-risk-in-”
Stated timescale: 2009
“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”
2 more stated actions in the Promises tab.
- 2 years 10 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There was no involvement of the family and so a source of important information was missed.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on”
- 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 → 2019Justin Gallagher2 years 10 months after Amy El-Keria · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of family involvement and input in the care of the individual as a critical failing. They describe how greater family contact could have provided important information and potentially altered outcomes.
Amy El-Keria · 3 Oct 2016
“The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”
Original on judiciary.uk ↗ Justin Gallagher · 16 Aug 2019
“There was no involvement of the family and so a source of important information was missed.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action · timescale: 2009
“The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK. website at the following address: https://www.gov.uk/government/publications/assessing-and-managing-risk-in-”
Stated action
“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”
Stated action
“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”
Stated action · timescale: 2020
“community where they live. NHS England and Health Education England (HEE) are working to improve the capacity and capability of workforce delivering mental health care for children and young people, so that by 2020 an additional 70,000 receive effective treatment per year. This work extends to supporting training programmes for staff working in inpatient CAMHS to improve team functioning and delivery of evidence-based care.”
Stated action
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on”
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 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 → 2019 | 0.78 | 0.20 | Identical · 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.