Fragmented transfer information across records
University Hospitals of Derby and Burton received 2 coroners' reports about this hazard between 14 Oct 2020 and 18 Oct 2022.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“That patient electronic and paper based transfer information is not kept on one database.”
Original on judiciary.uk ↗ University Hospitals of Derby and Burton responded.Response (PDF) ↗
- 2 years laterClosely relatedConfidence 0.90 · higha different coroner
“There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls”
Original on judiciary.uk ↗ University Hospitals of Derby and Burton responded.Response (PDF) ↗
- All reports to University Hospitals of Derby and Burton
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.
2020 → 2022Kenneth Perkins2 years after Edward Cowey · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that patient handover or transfer information is fragmented across separate records, preventing a complete view of the patient’s condition.
Edward Cowey · 14 Oct 2020
“That patient electronic and paper based transfer information is not kept on one database.”
Original on judiciary.uk ↗ Kenneth Perkins · 18 Oct 2022
“There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
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 University Hospitals of Derby and Burton 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 |
|---|---|---|---|---|
| 2020 → 2022 | 0.73 | 0.07 | Closely related · 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.