Inadequate clinical record keeping
Department of Health and Social Care received 2 coroners' reports about this hazard between 9 Jun 2014 and 8 May 2017.
They came from 2 different coroners 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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“He accepted in the course of his evidence that his record keeping was inadequate.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“A review of record keeping at HEE practice”
- 2 years 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”
Web search (Tavily): No evidence found either way
[PDF] Choking Incident Report Checklist - NJ.gov ↗ - 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.
2014 → 2017David Sheppard2 years 11 months after Daniel McCallum Keane · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports identify problems with clinical record keeping that hinder accurate reconstruction of patient care.
Daniel McCallum Keane · 9 Jun 2014
“He accepted in the course of his evidence that his record keeping was inadequate.”
Original on judiciary.uk ↗ David Sheppard · 8 May 2017
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Original on judiciary.uk ↗
Stated action
“A review of record keeping at HEE practice”
Stated action
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”
What happened next: No evidence found either way
The organisation's promised measures are described in a checklist and training resources, but no source confirms they were implemented.
“Utilize the checklist below to complete your initial incident report.”
“FirstAidTraining can teach you to: ✓Identify and treat a choking incident”
No evidence found does not mean the action did not happen.
- 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 |
|---|---|---|---|---|
| 2014 → 2017 | 0.73 | 0.25 | 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.