Inadequate verification of leave conditions
Coventry and Warwickshire Partnership NHS Trust received 2 coroners' reports about this hazard between 11 Dec 2020 and 4 Nov 2024.
They came from 2 different coroners 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.
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment”
Original on judiciary.uk ↗ Coventry and Warwickshire Partnership NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation”
- 3 years 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave.”
Original on judiciary.uk ↗ Coventry and Warwickshire Partnership NHS Trust responded.Response (PDF) ↗
- All reports to Coventry and Warwickshire Partnership 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.
2020 → 2024Darren Hope3 years 11 months after Katy Samuels · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that Section 17 leave conditions are not consistently verified or clarified before a patient is allowed leave. This gap in verification can compromise patient safety during unescorted leave.
Katy Samuels · 11 Dec 2020
“Leave should be planned in advance, agreed at the multidisciplinary team meeting and consideration must be given to the legal status of the patient.... Leave should only be granted after careful planning and risk assessment”
Original on judiciary.uk ↗ Darren Hope · 4 Nov 2024
“Section 17 leave conditions may not always be thoroughly reviewed or clarified before a service user is signed out for leave.”
Original on judiciary.uk ↗
Stated action
“The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation”
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 Coventry and Warwickshire Partnership 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 |
|---|---|---|---|---|
| 2020 → 2024 | 0.73 | 0.08 | Closely related · 0.90 | 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.