Inadequate death investigation with false statements and omitted GP requests
Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 14 Oct 2021 and 25 Mar 2024.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern.”
Original on judiciary.uk ↗ Nottinghamshire Healthcare NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The updated procedure will be shared with all staff via email and discussed with all staff via team meetings.”
Stated timescale: 31 December 2021
- 2 years 5 months later
Raised again · 1st time
Alexander Lyalushko↗
25 Mar 2024 · Amanda Bewley · Nottingham and Nottinghamshire
Closely relatedConfidence 0.78 · moderatea different coroner“it did not identify that a request from Mr [name redacted] GP in November 2022 for involvement of its service with Mr [name redacted] had not been actioned;”
Original on judiciary.uk ↗ Nottinghamshire Healthcare NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Nottinghamshire Healthcare 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.
2021 → 2024Alexander Lyalushko2 years 5 months after Paul Barton · different coronerClosely relatedConfidence 0.78 · moderate
Closely relatedConfidence 0.78 · moderateBoth reports criticize the Trust's death investigation processes for being inadequate and missing key information. The earlier report focuses on false statements and missed themes, while the later report highlights omitted GP requests, mislabelled findings, and lack of family consultation.
Paul Barton · 14 Oct 2021
“The quality of the Trust's own investigation into the circumstances of Mr [name redacted] death. It failed to identify themes of concern.”
Original on judiciary.uk ↗ Alexander Lyalushko · 25 Mar 2024
“it did not identify that a request from Mr [name redacted] GP in November 2022 for involvement of its service with Mr [name redacted] had not been actioned;”
Original on judiciary.uk ↗
Stated action · timescale: 31 December 2021
“The updated procedure will be shared with all staff via email and discussed with all staff via team meetings.”
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 Nottinghamshire Healthcare 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 |
|---|---|---|---|---|
| 2021 → 2024 | 0.72 | 0.05 | Closely related · 0.78 | 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.