Communication failures and information sharing problems across trust
Mid and South Essex NHS Foundation Trust received 2 coroners' reports about this hazard between 13 Dec 2024 and 20 Jul 2026.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“d. Communication issues with Trust staff and sharing of information”
Original on judiciary.uk ↗ Mid and South Essex NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
Stated timescale: 2025
- 1 year 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site.”
Original on judiciary.uk ↗ Mid and South Essex NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Mid and South Essex 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.
2024 → 2026Margaret Templeman1 year 7 months after Laura-Jane Seaman · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with communication and documentation within the Trust. The later report extends the concern to a trust‑wide, systemic issue rather than a single ward.
Laura-Jane Seaman · 13 Dec 2024
“d. Communication issues with Trust staff and sharing of information”
Original on judiciary.uk ↗ Margaret Templeman · 20 Jul 2026
“I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
Stated action · timescale: 2025
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
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 Mid and South Essex 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 |
|---|---|---|---|---|
| 2024 → 2026 | 0.64 | 0.04 | 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.