Lack of shared welfare check guidance
London Ambulance Service received 2 coroners' reports about this hazard between 21 Jul 2015 and 28 Sept 2021.
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.
“The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time.”
Original on judiciary.uk ↗ London Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“a Control Services Bulletin will be issued at the 15/89/2015 15:56 62077832889 LAS_LEGAL | PAGE 63/83 end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient being closed prior to assessment by a clinician.”
Stated timescale: end of September 2015
- 6 years 2 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact.”
Original on judiciary.uk ↗ London Ambulance Service responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to London Ambulance Service
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.
2015 → 2021Richard Boateng6 years 2 months after Anne Wilson · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight a lack of clear, shared guidance between the London Ambulance Service and other agencies (police or GPs) when handling welfare‑check requests, leading to potential gaps in patient safety.
Anne Wilson · 21 Jul 2015
“The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time.”
Original on judiciary.uk ↗ Richard Boateng · 28 Sept 2021
“The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“a Control Services Bulletin will be issued at the 15/89/2015 15:56 62077832889 LAS_LEGAL | PAGE 63/83 end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient being closed prior to assessment by a clinician.”
Stated action · timescale: end of September 2015
“a Control Services Bulletin will be issued at the 15/89/2015 15:56 62077832889 LAS_LEGAL | PAGE 63/83 end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient being closed prior to assessment by a clinician.”
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 London Ambulance Service 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 |
|---|---|---|---|---|
| 2015 → 2021 | 0.74 | 0.18 | Closely related · 0.80 | different |
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.