Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust received 3 coroners' reports about this hazard between 13 Jul 2022 and 24 Mar 2025.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Mr [name redacted] was passed between agencies without any lasting benefit.”
Original on judiciary.uk ↗ South West Yorkshire Partnership NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust will propose a meeting with its social care partner, [name redacted] Authority, to raise with them the contents of your report.”
- 10 months later
Raised again · 1st time
Mark Ravensdale↗
16 May 2023 · Abigail Combes · South Yorkshire (West District)
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
Original on judiciary.uk ↗ South West Yorkshire Partnership NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust will therefore develop and implement a triage checklist in respect of the review's findings.”
- 1 year 10 months laterIdentical hazardConfidence 0.90 · higha different coroner
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in”
Original on judiciary.uk ↗ Repeated from the earlier report:attemptsmentalhealth
South West Yorkshire Partnership NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“A new initiative of Integrated Co-occurring Needs (ICoN) is being set up in Barnsley that will bring together co-located workers from substance misuse services, mental health services and social care services to work with people with co-existing mental health and substance misuse issues.”
Stated timescale: July 2024
- All reports to South West Yorkshire Partnership 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.
2023 → 2025Claire Driver1 year 10 months after Mark Ravensdale · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight insufficient attempts by mental health services to engage patients directly in order to assess their mental health condition. They differ in the number of attempts (none versus two) and the specific circumstances.
Mark Ravensdale · 16 May 2023
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
Original on judiciary.uk ↗ Claire Driver · 24 Mar 2025
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust will therefore develop and implement a triage checklist in respect of the review's findings.”
2022 → 2025Claire Driver2 years 8 months after Daniel Clements · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient follow‑up and engagement with individuals experiencing suicidal or deteriorating mental health, leading to avoidable crises. The earlier case describes a patient being passed between agencies without lasting benefit, while the later case notes only two contacts by a community mental health team despite clear worsening.
Daniel Clements · 13 Jul 2022
“Mr [name redacted] was passed between agencies without any lasting benefit.”
Original on judiciary.uk ↗ Claire Driver · 24 Mar 2025
“there were only two attempts to see [the deceased] by the enhanced community mental health team”
Original on judiciary.uk ↗
Stated action
“the Trust will propose a meeting with its social care partner, [name redacted] Authority, to raise with them the contents of your report.”
Stated action
“The Trust will therefore develop and implement a triage checklist in respect of the review's findings.”
Stated action · timescale: July 2024
“A new initiative of Integrated Co-occurring Needs (ICoN) is being set up in Barnsley that will bring together co-located workers from substance misuse services, mental health services and social care services to work with people with co-existing mental health and substance misuse issues.”
- 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 West Yorkshire Partnership 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 |
|---|---|---|---|---|
| 2023 → 2025 | 0.67 | 0.18 | Identical · 0.90 | different |
| 2022 → 2025 | 0.67 | 0.08 | Closely related · 0.90 | 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.