Lack of discharge communication and coordinated care planning
Brighton and Sussex University Hospitals NHS Trust received 2 coroners' reports about this hazard between 3 Apr 2014 and 12 Aug 2015.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son.”
Original on judiciary.uk ↗ Brighton and Sussex University Hospitals NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily”
Stated timescale: 27 May 2014
Web search (Tavily): No evidence found either way
2025/26 Winter Planning Priorities - NHS Sussex ↗- 1 year 4 months laterClosely relatedConfidence 0.85 · high
“* firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU”
Original on judiciary.uk ↗ Repeated from the earlier report:regardeitherdischarge
Brighton and Sussex University Hospitals NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“We have carried out a careful review of the medical records with the appropriate personnel.”
Stated timescale: 7 November 2015
- All reports to Brighton and Sussex University Hospitals 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 → 2015Thelma Jones1 year 4 months after Graham Watts · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in communication and coordination around patient discharge planning. The earlier case cites absent discharge communication; the later case notes lack of joined‑up thinking about care, treatment, placement and discharge.
Graham Watts · 3 Apr 2014
“(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son.”
Original on judiciary.uk ↗ Thelma Jones · 12 Aug 2015
“* firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU”
Original on judiciary.uk ↗
Stated action · timescale: 27 May 2014
“the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily”
What happened next: No evidence found either way
The Trust's statement about daily practices on the ward is not referenced in any of the provided sources.
“The development of plan has been clinically led and will have strong clinical oversight of its implementation.”
“Read article](/resources/understanding-medically-fit-for-discharge-mffd-status-in-the-nhs)”
“A recent report by the [Health Service Journal](https://www.hsj.co.uk/quality-and-performance/2bn-cost-of-delayed-discharges-revealed-for-first-time/7040178.article) has revealed the £2bn cost of delayed discharges.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 7 November 2015
“We have carried out a careful review of the medical records with the appropriate personnel.”
- 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 Brighton and Sussex University Hospitals 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 → 2015 | 0.70 | 0.06 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Brighton and Sussex University Hospitals NHS 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.