Risk assessment not updated after formulation meeting
Tees received 2 coroners' reports about this hazard between 15 Aug 2016 and 20 Apr 2017.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
No published response from Tees was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm and suicide and details of conditions for escorted leave following the formulation meeting on 10" August 2015”
Original on judiciary.uk ↗ No published response from Tees was found for this report.
- 8 months laterClosely relatedConfidence 0.85 · higha different coroner
“There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.”
Original on judiciary.uk ↗ Repeated from the earlier report:Parisnotes
The most recent report. A response may not be due or published yet.
- All reports to Tees
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 → 2017Thomas Whitfield8 months after Michael McMonigle · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in documenting suicide/self‑harm risk information within the Paris notes system.
Michael McMonigle · 15 Aug 2016
“The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm and suicide and details of conditions for escorted leave following the formulation meeting on 10" August 2015”
Original on judiciary.uk ↗ Thomas Whitfield · 20 Apr 2017
“There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.”
Original on judiciary.uk ↗
No published response from Tees was found for this report.
No published response from Tees was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Tees 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 → 2017 | 0.64 | 0.08 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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.