Insufficient alertness of healthcare staff to physical symptoms occluded by mental health issues
Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 3 May 2016 and 5 Jan 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues.”
Original on judiciary.uk ↗ No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for this report.
- 7 years 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Poor Quality Acute Physical Healthcare in the mental health setting [the deceased]'s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention.”
Original on judiciary.uk ↗ Repeated from the earlier report:PhysicalHealthcarementalhealthmedicalstaff
Nottinghamshire Healthcare NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”
Stated timescale: next 12 months
- All reports to Nottinghamshire Healthcare 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.
2016 → 2024Tammy Watkins7 years 8 months after Shalane Blackwood · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that medical staff fail to notice serious physical illness because mental health factors obscure the symptoms.
Shalane Blackwood · 3 May 2016
“That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues.”
Original on judiciary.uk ↗ Tammy Watkins · 5 Jan 2024
“Poor Quality Acute Physical Healthcare in the mental health setting [the deceased]'s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention.”
Original on judiciary.uk ↗
No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for this report.
Stated action · timescale: next 12 months
“The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”
- 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 Nottinghamshire Healthcare 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 |
|---|---|---|---|---|
| 2016 → 2024 | 0.69 | 0.13 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Nottinghamshire Healthcare NHS Foundation Trust
- Inadequate information sharing between healthcare teams2 reports · 2016–2026
- Inadequate foreign body management guidance2 reports · 2024–2025
- Inaccurate and poor record keeping in custody suite2 reports · 2020–2024
- Inadequate death investigation with false statements and omitted GP requests2 reports · 2021–2024
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.