Inadequate documentation and communication of discharge decisions
South London and Maudsley NHS Foundation Trust received 2 coroners' reports about this hazard between 20 Aug 2013 and 19 May 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from South London and Maudsley NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”
Original on judiciary.uk ↗ No published response from South London and Maudsley NHS Foundation Trust was found for this report.
- 12 years 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth”
Original on judiciary.uk ↗ South London and Maudsley NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to South London and Maudsley 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.
2013 → 2026Catherine Morgan12 years 9 months after Nicola Matthews · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight inadequate documentation and communication of decisions regarding patient discharge or leave. This leads to unclear follow‑up arrangements and potential harm.
Nicola Matthews · 20 Aug 2013
“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”
Original on judiciary.uk ↗ Catherine Morgan · 19 May 2026
“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth”
Original on judiciary.uk ↗
No published response from South London and Maudsley NHS Foundation Trust was found for this report.
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 South London and Maudsley 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 |
|---|---|---|---|---|
| 2013 → 2026 | 0.67 | 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 South London and Maudsley NHS Foundation Trust
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.