Lack of discharge planning in mental health services
Pennine Care NHS Trust received 2 coroners' reports about this hazard between 30 Jan 2014 and 19 Apr 2018.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
No published response from Pennine Care NHS Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The discharge planning in relation to Mr [name redacted] was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this.”
Original on judiciary.uk ↗ No published response from Pennine Care NHS Trust was found for this report.
- 4 years 3 months laterClosely relatedConfidence 0.85 · higha different coroner
“there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward;”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
Stated timescale: next two to three and a half years
“We revised the Code of Practice in 2015 and set out guiding principles to ' hups://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983 improve the care for patients.”
Stated timescale: 2015
1 more stated action in the Promises tab.
- All reports to Pennine Care NHS 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.
2014 → 2018Adrian Jennings4 years 3 months after Gareth Slater · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with discharge planning for mental health patients within Pennine Care NHS Trust. The earlier report cites specific failures in carrying out discharge planning due to clinical disagreement, while the later report points to the absence of a coordinated system for primary and secondary services to create a joined‑up discharge plan.
Gareth Slater · 30 Jan 2014
“The discharge planning in relation to Mr [name redacted] was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this.”
Original on judiciary.uk ↗ Adrian Jennings · 19 Apr 2018
“there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward;”
Original on judiciary.uk ↗
No published response from Pennine Care NHS Trust was found for this report.
Stated action · timescale: next two to three and a half years
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
Stated action · timescale: 2015
“We revised the Code of Practice in 2015 and set out guiding principles to ' hups://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983 improve the care for patients.”
Stated action · timescale: process of investing
“The Tameside and Glossop Strategic Commissioning Board has recognised the need to develop and expand mental health support and is in the process of investing in additional services”
- 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 Pennine Care NHS 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 |
|---|---|---|---|---|
| 2014 → 2018 | 0.73 | 0.12 | Closely related · 0.85 | 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.