Delayed resolution of outstanding safety issues
Avon and Wiltshire Mental Health Partnership NHS Trust received 2 coroners' reports about this hazard between 14 Nov 2016 and 13 Dec 2017.
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.
“The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.”
Original on judiciary.uk ↗ Avon and Wiltshire Mental Health Partnership NHS Trust responded.Response (PDF) ↗
- 1 year 1 month laterClosely relatedConfidence 0.85 · higha different coroner
“Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so again expectations are managed and everyone knows exactly what the plan is and when actions will occur.”
Original on judiciary.uk ↗ Repeated from the earlier report:careplan
The most recent report. A response may not be due or published yet.
- All reports to Avon and Wiltshire Mental Health Partnership NHS 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.
2016 → 2017Rebecca Romero1 year 1 month after Martyn Watkins · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight the need for timely planning and scheduling of care activities to ensure safety. They differ in focus: the earlier concerns a ward‑wide timetable and action plan, while the later stresses time‑specific care plans for individual patients.
Martyn Watkins · 14 Nov 2016
“The CQC should satisfy themselves that an appropriate timetable and action plan are in place to ensure any outstanding issues on Aspen Ward relating to the safe care and treatment of service users are addressed at the earliest opportunity.”
Original on judiciary.uk ↗ Rebecca Romero · 13 Dec 2017
“Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so again expectations are managed and everyone knows exactly what the plan is and when actions will occur.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No published response from Avon and Wiltshire Mental Health Partnership NHS Trust 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 Avon and Wiltshire Mental Health Partnership NHS 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 |
|---|---|---|---|---|
| 2016 → 2017 | 0.69 | 0.03 | 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 Avon and Wiltshire Mental Health Partnership NHS 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.