Inadequate communication between health care departments
NHS Digital received 2 coroners' reports about this hazard between 24 Nov 2020 and 14 Jul 2023.
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.
“Different health care departments have different patient care records and the departments did not communicate with one another.”
Original on judiciary.uk ↗ NHS Digital responded, stating 1 specific action.Response (PDF) ↗
“We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.”
- 2 years 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“different health organisations use different digital systems that do not communicate with each other.”
Original on judiciary.uk ↗ Repeated from the earlier report:differenthealthcommunicate
NHS Digital responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to NHS Digital
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.
2020 → 2023Peter Fleming2 years 8 months after David Ball · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that separate health organisations maintain independent patient record systems that do not share information, hindering communication.
David Ball · 24 Nov 2020
“Different health care departments have different patient care records and the departments did not communicate with one another.”
Original on judiciary.uk ↗ Peter Fleming · 14 Jul 2023
“different health organisations use different digital systems that do not communicate with each other.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.”
Stated action
“We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 NHS Digital 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 |
|---|---|---|---|---|
| 2020 → 2023 | 0.68 | 0.10 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for NHS Digital
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.