Lack of risk assessment before critical decision
Care Quality Commission received 2 coroners' reports about this hazard between 25 Jul 2016 and 5 Apr 2019.
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.
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We will be meeting with the Trust again in December 2016 to review the impact of their action plans.”
Stated timescale: December 2016
“NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and community/primary care work streams. The acute care work stream has been developed in response to a number of recommendations set out by the Commission on Acute Adult Psychiatric Care and The Five Year Forward View for Mental Health, and is particularly relevant to the concerns outlined in your report.”
Stated timescale: 2020/21
Web search (Tavily): No evidence found either way
OLD PROBLEMS, NEW SOLUTIONS: ↗- 2 years 8 months laterClosely relatedConfidence 0.85 · higha different coroner
“(c) no risk assessment was carried out prior to making the decision to return his call bell.”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessment
The most recent report. A response may not be due or published yet.
- All reports to Care Quality Commission
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 → 2019Yong Hong2 years 8 months after Patricia Cleghorn · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that a necessary risk assessment was not performed before a critical decision. The earlier case concerned medication availability, while the later case concerned GP input and call‑bell return.
Patricia Cleghorn · 25 Jul 2016
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.”
Original on judiciary.uk ↗ Yong Hong · 5 Apr 2019
“(c) no risk assessment was carried out prior to making the decision to return his call bell.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will take action with regards to managing the breach of policy The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for: Clinical Risk Assessments regarding risk of self-harm and/or suicide; Risk Assessments with regard to medicines management and self-medication; Safe administration of medication as per current Medicines Code and NMC Code.”
Stated action · timescale: December 2016
“We will be meeting with the Trust again in December 2016 to review the impact of their action plans.”
Stated action · timescale: 2020/21
“NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and community/primary care work streams. The acute care work stream has been developed in response to a number of recommendations set out by the Commission on Acute Adult Psychiatric Care and The Five Year Forward View for Mental Health, and is particularly relevant to the concerns outlined in your report.”
What happened next: No evidence found either way
The NHS England adult mental health programme was described as a whole-system initiative with an acute care work stream developed in response to recommendations, but no source confirms it was operational by 2020/21.
“The Commission to review the provision of acute inpatient psychiatric care for adults FEBRUARY 2016 OLD PROBLEMS, NEW SOLUTIONS: Improving acute psychiatric care for adults in England FINAL REPORT Old Problems, New Solutions: Improving Acute Psychiatric Care for Adults in England Published: February 2016 The independent Commission on Acute Adult Psychiatric Care was set up by the Royal College of”
“Mental Health - Adult Crisis and Acute Care GIRFT Programme National Specialty Report By Dr [name redacted] GIRFT Clinical Lead April 2021 GIRFT is delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust, NHS England and NHS Improvement 2 Contents Foreword................................................................................................................”
“CLINICAL PERFORMANCE STANDARDS Extended Acute Care (EAC) Services Updated March 2026 CPS: EXTENDED ACUTE CARE (EAC) SERVICES Updated March 2026 2 TABLE OF CONTENTS 1. Purpose ......................................................................................................................................................... 3 2. Scope of Services ..................................”
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 Care Quality Commission 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 | 0.77 | 0.08 | Closely related · 0.85 | 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.