Inadequate supervision and documentation of junior doctors
Greater Manchester Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 13 Dec 2013 and 20 Dec 2019.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen.”
Original on judiciary.uk ↗ Greater Manchester Mental Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases.”
- 6 years laterClosely relatedConfidence 0.80 · moderate
“It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff”
Original on judiciary.uk ↗ Greater Manchester Mental Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
- All reports to Greater Manchester Mental Health NHS Foundation Trust
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 → 2019Tomasz Nowasad6 years after Stephanie Daniels · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in ensuring proper clinical documentation and oversight of junior staff's record‑keeping practices.
Stephanie Daniels · 13 Dec 2013
“it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen.”
Original on judiciary.uk ↗ Tomasz Nowasad · 20 Dec 2019
“It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff”
Original on judiciary.uk ↗
Stated action
“the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases.”
Stated action
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
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 Greater Manchester Mental Health NHS Foundation Trust 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 → 2019 | 0.77 | 0.12 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Greater Manchester Mental Health NHS Foundation Trust
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.