Absence of learning disability liaison nurse support
Department of Health and Social Care received 2 coroners' reports about this hazard between 30 Sept 2019 and 13 May 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“In June 2018, NHS Improvement published Learning Disability Improvement Standards for NHS trusts in England'. The Standards are intended to help NHS trusts measure the quality of service they provide to people with learning disabilities, autism or both”
Stated timescale: June 2018
- 5 years 7 months laterIdentical hazardConfidence 0.92 · higha different coroner
“there was no consideration or offer given to [the deceased] or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse”
Original on judiciary.uk ↗ Repeated from the earlier report:learningDisabilityLiaison
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗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.
2019 → 2025Rose Harfleet5 years 7 months after Julie Barrow · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight the absence of a learning disability liaison nurse or role, which left patients and families without needed support and advocacy.
Julie Barrow · 30 Sept 2019
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people”
Original on judiciary.uk ↗ Rose Harfleet · 13 May 2025
“there was no consideration or offer given to [the deceased] or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse”
Original on judiciary.uk ↗
Stated action · timescale: June 2018
“In June 2018, NHS Improvement published Learning Disability Improvement Standards for NHS trusts in England'. The Standards are intended to help NHS trusts measure the quality of service they provide to people with learning disabilities, autism or both”
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.
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 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 |
|---|---|---|---|---|
| 2019 → 2025 | 0.72 | 0.34 | Identical · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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.