Inadequate risk assessment for self-harm patients
Sheffield Health and Social Care NHS Foundation Trust received 2 coroners' reports about this hazard between 3 Feb 2015 and 20 Nov 2023.
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 Sheffield Health and Social Care NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“It was accepted at the inquest that more could have been taken into account in risk assessing Mr [name redacted].”
Original on judiciary.uk ↗ No published response from Sheffield Health and Social Care NHS Foundation Trust was found for this report.
- 8 years 10 months later
Raised again · 1st time
Gareth Etchells-Height↗
20 Nov 2023 · Alexandra Pountney · South Yorkshire (Western)
Closely relatedConfidence 0.80 · moderatea different coroner“There was a failure to update [the deceased]'s risk assessment, which at the date of his death was last updated on 7 April 2022.”
Original on judiciary.uk ↗ Sheffield Health and Social Care NHS Foundation Trust responded, stating 10 specific actions.Response (PDF) ↗Response (PDF) ↗
“We will complete and audit existing practice in relation to the completion of our discharge summaries and the process and documentation in support of safety netting. We will also review the format and function of our existing discharge templates. These tasks will be completed by the end of February 2024.”
Stated timescale: end of February 2024
“The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team.”
Stated timescale: end of June 2024
8 more stated actions in the Promises tab.
- All reports to Sheffield Health and Social Care 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 → 2023Gareth Etchells-Height8 years 10 months after Alexander Holt · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight inadequacies in the risk assessment process for patients at risk of self‑harm. The earlier report notes that more factors should have been considered, while the later report finds that the existing assessment was not updated despite changes in the patient’s condition.
Alexander Holt · 3 Feb 2015
“It was accepted at the inquest that more could have been taken into account in risk assessing Mr [name redacted].”
Original on judiciary.uk ↗ Gareth Etchells-Height · 20 Nov 2023
“There was a failure to update [the deceased]'s risk assessment, which at the date of his death was last updated on 7 April 2022.”
Original on judiciary.uk ↗
No published response from Sheffield Health and Social Care NHS Foundation Trust was found for this report.
Stated action · timescale: end of February 2024
“We will complete and audit existing practice in relation to the completion of our discharge summaries and the process and documentation in support of safety netting. We will also review the format and function of our existing discharge templates. These tasks will be completed by the end of February 2024.”
Stated action · timescale: end of June 2024
“The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team.”
Stated action · timescale: 30 April 2024
“The Directorate Leadership Team will develop a Standard Operating Procedure covering 'how to prepare for a clinical review` which will include what documentation should be read as part of the preparation for this by 30 April 2024.”
Stated action
“The individual practitioners involved in the review of care are aware of the importance of reviewing and updating risk assessments for individual clients. As we move to our new electronic patient record, this will give us opportunity to set review requirements as an automated reminder in addition to individual clinical judgement.”
Stated action
“We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.”
Stated action
“The implementation of the system has been delayed for some services in the Trust, however, the functionality of RIO will bring about significant automated improvements in record keeping.”
Stated action · timescale: 30 June 2024
“The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary.”
Stated action
“We developed a clinical record keeping standards policy earlier this year to provide clarity on the expected requirements to ensure high quality, person centred clinical documentation across the Trust.”
Stated action
“Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update.”
Stated action
“All staff have been reminded about the importance of good quality record keeping through an alert cascade that was produced, disseminated and published on the staff intranet.”
- 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 Sheffield Health and Social Care 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 → 2023 | 0.64 | 0.04 | Closely related · 0.80 | 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.