Lack of communication and care coordination in placement decisions
Greater Manchester Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 24 Jul 2019 and 4 May 2020.
They came from 1 coroner in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Greater Manchester Mental Health NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“During the time that [the deceased] was placed at the Priory the mental health trust who placed her did not have any discussion with [the deceased], her family or the Priory regarding the placement.”
Original on judiciary.uk ↗ No published response from Greater Manchester Mental Health NHS Foundation Trust was found for this report.
- 9 months later
Raised again · 1st time
Barry Preston↗
4 May 2020 · Alison Mutch · Manchester; Greater Manchester South
Closely relatedConfidence 0.80 · moderate“The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement.”
Original on judiciary.uk ↗ Greater Manchester Mental Health NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Greater Manchester Mental Health 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.
2019 → 2020Barry Preston9 months after Hannah Bharaj · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in coordinating and communicating placement decisions for patients, leading to unsuitable settings.
Hannah Bharaj · 24 Jul 2019
“During the time that [the deceased] was placed at the Priory the mental health trust who placed her did not have any discussion with [the deceased], her family or the Priory regarding the placement.”
Original on judiciary.uk ↗ Barry Preston · 4 May 2020
“The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement.”
Original on judiciary.uk ↗
No published response from Greater Manchester Mental Health NHS Foundation Trust was found for this report.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Greater Manchester Mental Health 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 |
|---|---|---|---|---|
| 2019 → 2020 | 0.70 | 0.15 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Greater Manchester Mental Health 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.