Limited family involvement in care planning and risk assessment
Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 1 Sept 2023 and 4 Mar 2024.
They came from 1 coroner. 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.
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
Original on judiciary.uk ↗ Nottinghamshire Healthcare NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗
“To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”
“an electronic device is being procured which will allow multiple alarms to be set for each person's leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot.”
4 more stated actions in the Promises tab.
- 6 months laterIdentical hazardConfidence 0.90 · high
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”
Original on judiciary.uk ↗ Repeated from the earlier report:Familycareplan
Nottinghamshire Healthcare NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Nottinghamshire Healthcare 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.
2023 → 2024Kenneth Baylis6 months after Gerard Murray · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the lack of routine family and carer participation in patients' risk assessments, care planning and safety processes.
Gerard Murray · 1 Sept 2023
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
Original on judiciary.uk ↗ Kenneth Baylis · 4 Mar 2024
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Triangle of care process has also been strengthened as part of our ongoing quality improvement plans. Our Quality Standards Team also undertake reviews of Care Plans and look for clear evidence that these plans are produced with the patient, family and carers.”
Stated action
“To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”
Stated action
“an electronic device is being procured which will allow multiple alarms to be set for each person's leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot.”
Stated action
“To ensure there is consistent compliance with the door board system, a checking process has been incorporated in the Senior Nurse's daily observation spot checks. This includes a band 6 nurse or above observing staff completing their observations rounds, and quality checking their understanding and performance within the role.”
Stated action
“The Triangle of care process has also been strengthened as part of our ongoing quality improvement plans. Our Quality Standards Team also undertake reviews of Care Plans and look for clear evidence that these plans are produced with the patient, family and carers.”
Stated action
“all-acute wards have recruited a Carer Peer Support worker whose working week is dedicated to liaising with patients and their families/carers and ensuring the link with MDT members, and clinical discussions is strong.”
Stated action
“It is foreseen that the Policy will recommend that clinical teams will receive training in the clinical risk assessment tools employed by each service, The training will be sourced from external providers or developed with the learning and development team to make sure that the learning materials reflect the Policy requirements and the individual needs of the people that we support.”
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 Nottinghamshire Healthcare 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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.65 | 0.13 | Identical · 0.90 | same |
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.