Lack of continuity of care due to excessive care team members
Norfolk and Suffolk NHS Foundation Trust received 2 coroners' reports about this hazard between 23 Mar 2015 and 13 Mar 2019.
They came from 1 coroner. 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.
“Although seen regularly by the Crisis Team, Mrs [name redacted] was seen by a number of different people as a result of which no trusting relationship could be established.”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust is planning to review the functions of the CRHT over the forthcoming months. Included within this review will be how we can improve the consistency of staff engaged with the service user. | would like to provide you with an update on progress in early September.”
Stated timescale: early September
- 4 years laterIdentical hazardConfidence 0.92 · high
“Miss [name redacted] repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team.”
Original on judiciary.uk ↗ Repeated from the earlier report:numberpeopleCrisisTeam
Norfolk and Suffolk NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Norfolk and Suffolk 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.
2015 → 2019Tamsin Grundy4 years after Barbara Mayer · same coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight that patients were seen by numerous different staff members, preventing a trusting relationship and requiring them to repeat their personal history. This lack of continuity of care is the core concern in each case.
Barbara Mayer · 23 Mar 2015
“Although seen regularly by the Crisis Team, Mrs [name redacted] was seen by a number of different people as a result of which no trusting relationship could be established.”
Original on judiciary.uk ↗ Tamsin Grundy · 13 Mar 2019
“Miss [name redacted] repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust is planning to review the functions of the CRHT over the forthcoming months. Included within this review will be how we can improve the consistency of staff engaged with the service user. | would like to provide you with an update on progress in early September.”
Stated action · timescale: early September
“The Trust is planning to review the functions of the CRHT over the forthcoming months. Included within this review will be how we can improve the consistency of staff engaged with the service user. | would like to provide you with an update on progress in early September.”
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 Norfolk and Suffolk 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 |
|---|---|---|---|---|
| 2015 → 2019 | 0.72 | 0.12 | Identical · 0.92 | 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.