Unclear hospital transfer process and forms
NHS England received 2 coroners' reports about this hazard between 17 Feb 2017 and 13 Dec 2017.
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 lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Web search (Tavily): Evidence found that the action was carried out
Health and Justice Commissioning Intentions 2015/16 ↗- 10 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure.”
Original on judiciary.uk ↗ Repeated from the earlier report:confusiontransfer
The most recent report. A response may not be due or published yet.
- 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.
2017 → 2017Rebecca Romero10 months after Dean Saunders · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight uncertainty and lack of clear documentation around the transfer of patients between settings.
Dean Saunders · 17 Feb 2017
“The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”
Original on judiciary.uk ↗ Rebecca Romero · 13 Dec 2017
“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Stated action
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
What happened next: Evidence found that the action was carried out
The document indicates that NHS England is involved in commissioning healthcare for police custody, including plans to transfer responsibility by 2016.
“The commissioning of Healthcare for Police Custody Suites is to transfer to NHS England by 2016. This work will continue to be developed and”
No published response from NHS England was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 |
|---|---|---|---|---|
| 2017 → 2017 | 0.77 | 0.10 | 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.