Discharge without follow up arrangements
South London and Maudsley NHS Foundation Trust received 2 coroners' reports about this hazard between 20 Aug 2013 and 9 May 2014.
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.
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented.”
Original on judiciary.uk ↗ No published response from South London and Maudsley NHS Foundation Trust was found for this report.
- 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded.”
Original on judiciary.uk ↗ South London and Maudsley NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust's policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”
- 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 → 2014Gary Richards9 months after Nicola Matthews · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that patients discharged from inpatient care were not ensured proper follow‑up due to missing or unclear arrangements. The earlier report stresses undocumented follow‑up plans, while the later report notes absent contact details preventing any follow‑up.
Nicola Matthews · 20 Aug 2013
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented.”
Original on judiciary.uk ↗ Gary Richards · 9 May 2014
“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded.”
Original on judiciary.uk ↗
No published response from South London and Maudsley NHS Foundation Trust was found for this report.
Stated action
“The Trust's policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”
- 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 → 2014 | 0.69 | 0.03 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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.