Inaccurate and poor record keeping in custody suite
Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 28 Aug 2020 and 4 Oct 2024.
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 Nottinghamshire Healthcare NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;”
Original on judiciary.uk ↗ No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for this report.
- 4 years 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“a) That there remain potential issues of poor record keeping. b) There are concerns over the level of communication between professionals within the Trust and communication with patients.”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeeping
Nottinghamshire Healthcare NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Nottinghamshire Healthcare 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.
2020 → 2024James Southern4 years 1 month after Carlington Spencer · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight deficiencies in record keeping within the Trust. The earlier report ties this to observations of intoxicated detainees, while the later report notes ongoing poor record keeping without specifying context.
Carlington Spencer · 28 Aug 2020
“Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;”
Original on judiciary.uk ↗ James Southern · 4 Oct 2024
“a) That there remain potential issues of poor record keeping. b) There are concerns over the level of communication between professionals within the Trust and communication with patients.”
Original on judiciary.uk ↗
No published response from Nottinghamshire Healthcare NHS Foundation Trust was found for this report.
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 Nottinghamshire Healthcare 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 |
|---|---|---|---|---|
| 2020 → 2024 | 0.63 | 0.18 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Nottinghamshire Healthcare NHS Foundation Trust
- Inadequate information sharing between healthcare teams2 reports · 2016–2026
- Inadequate foreign body management guidance2 reports · 2024–2025
- Inadequate death investigation with false statements and omitted GP requests2 reports · 2021–2024
- Lack of staff awareness and audit of home leave policy2 reports · 2015–2024
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.