Locum registrar without assessment or supervision
Department of Health and Social Care received 2 coroners' reports about this hazard between 3 Feb 2020 and 11 Jun 2025.
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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 5 specific actions.Response (PDF) ↗
“the CQC continues to be in close contact with the Trust and will take regulatory action if it decides that it is necessary”
“England and NHS Improvement (NHSEI) have put in place an intensive programme of support at the Trust”
3 more stated actions in the Promises tab.
- 5 years 4 months laterClosely relatedConfidence 0.70 · moderatea different coroner
“I am concerned that no medical record appears to exist of the examination of [the deceased] which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital.”
Original on judiciary.uk ↗ Repeated from the earlier report:LocumRegistrarhospital
Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2020 → 2025Lila Marsland5 years 4 months after Harry Richford · different coronerClosely relatedConfidence 0.70 · moderate
Closely relatedConfidence 0.70 · moderateBoth reports highlight problems with the handling of locum registrars: the earlier report notes a lack of skill assessment and supervision, while the later report points to missing medical records of a locum registrar's examination. They share the concern that locum registrars are not properly evaluated or documented.
Harry Richford · 3 Feb 2020
“was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital.”
Original on judiciary.uk ↗ Lila Marsland · 11 Jun 2025
“I am concerned that no medical record appears to exist of the examination of [the deceased] which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital.”
Original on judiciary.uk ↗
Stated action
“the CQC continues to be in close contact with the Trust and will take regulatory action if it decides that it is necessary”
Stated action
“England and NHS Improvement (NHSEI) have put in place an intensive programme of support at the Trust”
Stated action
“The Trust must continue to strengthen its processes to learn from deaths and develop an open, learning culture for the safety of its patients”
Stated action
“the Trust has developed its approach to engaging with families when unexpected deaths occur and to involve families in the investigation of these 2”
Stated action
“the Trust Board is taking these matters very seriously and has welcomed the national support being provided.”
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2020 → 2025 | 0.69 | 0.38 | Closely related · 0.70 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
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.