Lack of multidisciplinary coordination of care
Northumberland received 3 coroners' reports about this hazard between 6 Dec 2019 and 29 Feb 2024.
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 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.”
Original on judiciary.uk ↗ No published response from Northumberland was found for this report.
- 1 year 5 months later
“- the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;”
Original on judiciary.uk ↗ Northumberland responded, stating 1 specific action.Response (PDF) ↗
“the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”
Stated timescale: 27 July 2021
- 2 years 9 months later
Raised again · 2nd time
Christopher Vickers↗
29 Feb 2024 · Leila Benyounes · Gateshead and South Tyneside
Closely relatedConfidence 0.90 · higha different coroner“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
Original on judiciary.uk ↗ Repeated from the earlier report:caremulti-disciplinary
Northumberland responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Northumberland
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.
2021 → 2024Christopher Vickers2 years 9 months after Richard Burgess · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in ensuring effective multidisciplinary coordination of care for individuals with complex needs. The earlier report notes insufficient multidisciplinary team provision, while the later report describes missed opportunities to use multidisciplinary and multi-agency meetings despite known risks.
Richard Burgess · 19 May 2021
“- the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;”
Original on judiciary.uk ↗ Christopher Vickers · 29 Feb 2024
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
Original on judiciary.uk ↗ 2019 → 2024Christopher Vickers4 years 3 months after Maureen Wharton · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in coordinating care across different agencies or services. The earlier report notes the absence of any arrangement to involve other agencies, while the later report describes repeated missed chances to use existing multi‑disciplinary and multi‑agency meetings.
Maureen Wharton · 6 Dec 2019
“No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.”
Original on judiciary.uk ↗ Christopher Vickers · 29 Feb 2024
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
Original on judiciary.uk ↗
No published response from Northumberland was found for this report.
Stated action · timescale: 27 July 2021
“the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”
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 Northumberland 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 |
|---|---|---|---|---|
| 2021 → 2024 | 0.65 | 0.01 | Closely related · 0.90 | different |
| 2019 → 2024 | 0.69 | 0.04 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Northumberland
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.