Lack of timely crisis team visits and communication
Camden and Islington NHS Foundation Trust received 2 coroners' reports about this hazard between 1 Jun 2015 and 24 Aug 2017.
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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
Original on judiciary.uk ↗ Camden and Islington NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”
- 2 years 3 months laterClosely relatedConfidence 0.90 · high
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
Original on judiciary.uk ↗ Camden and Islington NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“we have asked to be provided with copies of CANDI's finalised Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately”
“The nurse in question was an agency professional, employed by NHS Professionals. (NHSP). tn light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed.”
Stated timescale: November
- All reports to Camden and Islington 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 → 2017Jonathan Meaney2 years 3 months after Mark Daniels · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures to properly assess and respond to patients expressing suicidal intent, leading to inadequate care and premature discharge.
Mark Daniels · 1 Jun 2015
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
Original on judiciary.uk ↗ Jonathan Meaney · 24 Aug 2017
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”
Stated action
“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”
Stated action
“we have asked to be provided with copies of CANDI's finalised Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately”
Stated action · timescale: November
“The nurse in question was an agency professional, employed by NHS Professionals. (NHSP). tn light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed.”
- 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 Camden and Islington 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 → 2017 | 0.69 | 0.08 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Camden and Islington NHS Foundation Trust
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.