Sequential treatment of dual diagnosis
Cornwall NHS Trust received 2 coroners' reports about this hazard between 7 Jun 2018 and 11 Feb 2019.
They came from 1 coroner 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 approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed.”
Original on judiciary.uk ↗ Cornwall NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust will be working in partnership with NHS Kernow as outlined in their response”
Stated timescale: September 2018
- 8 months laterClosely relatedConfidence 0.90 · high
“The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT.”
Original on judiciary.uk ↗ Repeated from the earlier report:dualdiagnosis
Cornwall NHS Trust responded.Response (PDF) ↗
- All reports to Cornwall 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.
2018 → 2019Paul Gillam8 months after Marcus Hance · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern how dual diagnosis cases are managed, specifically the sequencing of substance misuse and mental health treatment and the coordination between services.
Marcus Hance · 7 Jun 2018
“The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed.”
Original on judiciary.uk ↗ Paul Gillam · 11 Feb 2019
“The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT.”
Original on judiciary.uk ↗
Stated action · timescale: September 2018
“the Trust will be working in partnership with NHS Kernow as outlined in their response”
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 Cornwall 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 |
|---|---|---|---|---|
| 2018 → 2019 | 0.67 | 0.24 | Closely related · 0.90 | same |
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.