Fragmented mental health record keeping
Greater Manchester Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 3 May 2022 and 2 Oct 2024.
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 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
Original on judiciary.uk ↗ Greater Manchester Mental Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”
Stated timescale: end of July 2022
- 2 years 5 months laterClosely relatedConfidence 0.86 · higha different coroner
“The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealth
Greater Manchester Mental Health NHS Foundation Trust responded, stating 5 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient's responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions”
Stated timescale: 6 November 2024
“I will therefore provide some further information on the work NWAS is undertaking with its partner agencies who are also often called upon to assist mental health patients.”
3 more stated actions in the Promises tab.
- 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.
2022 → 2024Michael Heath2 years 5 months after Kate Hedges · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight problems arising from fragmented mental‑health record keeping that prevent clinicians from accessing complete patient information.
Kate Hedges · 3 May 2022
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
Original on judiciary.uk ↗ Michael Heath · 2 Oct 2024
“The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”
Stated action · timescale: end of July 2022
“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”
Stated action · timescale: 6 November 2024
“the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient's responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions”
Stated action
“I will therefore provide some further information on the work NWAS is undertaking with its partner agencies who are also often called upon to assist mental health patients.”
Stated action
“The Training Manager for GMP's Force Contact Crime and Operations Branch (FCCO) has confirmed that the Mental Health induction input for their staff is 3.5 hours long. This is included in all new recruit training into Call Handling and Dispatch.”
No specific action could be extracted with a verified quote.
Stated action · timescale: due course
“England will review and consider carefully the other responses in due course.”
Stated action · timescale: 27 November 2024
“We have introduced six new evidence categories to organise information under the statements; these are 'Feedback from people', 'Feedback from staff and leaders', 'Feedback from partners', 'Our observations', 'Processes' and 'Outcomes'. This approach will allow CQC to use a range of information to assess providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at any time; tailor our assessment to different types of providers and services; score evidence to make”
- 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 |
|---|---|---|---|---|
| 2022 → 2024 | 0.70 | 0.04 | Closely related · 0.86 | different |
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
- Inadequate discharge medication risk assessment2 reports · 2019–2023
- Inadequate audit of observations and documentation3 reports · 2013–2022
- Lack of communication and care coordination in placement decisions2 reports · 2019–2020
- Inadequate supervision and documentation of junior doctors2 reports · 2013–2019
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.