Incomplete patient transfer information
NHS England received 2 coroners' reports about this hazard between 4 Feb 2020 and 14 Oct 2020.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“the Trust has responded to address the specific learning with regard their own internal patient transfer processes.”
- 8 months laterClosely relatedConfidence 0.85 · high
“Evidence emerged during the inquest 1. That patient electronic and paper based transfer information is not kept on one database.”
Original on judiciary.uk ↗ Repeated from the earlier report:Evidenceemergedduringinquestpatientelectronic
NHS England responded.Response (PDF) ↗
- All reports to NHS England
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 → 2020Edward Cowey8 months after Maureen Brown · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that patient transfer information is incomplete or fragmented, leading to potential gaps in handover. The earlier report cites limits of the electronic transfer system, while the later report notes information split across multiple databases and formats.
Maureen Brown · 4 Feb 2020
“Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred.”
Original on judiciary.uk ↗ Edward Cowey · 14 Oct 2020
“Evidence emerged during the inquest 1. That patient electronic and paper based transfer information is not kept on one database.”
Original on judiciary.uk ↗
Stated action
“the Trust has responded to address the specific learning with regard their own internal patient transfer processes.”
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 NHS England 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 → 2020 | 0.82 | 0.21 | Closely related · 0.85 | 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.