Inadequate serious incident investigation process
Leicestershire Partnership NHS Trust received 2 coroners' reports about this hazard between 14 Aug 2023 and 13 Jun 2024.
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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
First warning
Marie Zarins↗
14 Aug 2023 · Isobel Thistlethwaite · Leicester City and South Leicestershire
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
Original on judiciary.uk ↗ Leicestershire Partnership NHS Trust responded, stating 5 specific actions.Response (PDF) ↗
“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”
“The Trust was unable to contact the Locum Consultant for input into the original SI investigation due to not holding the latest contact details; the Locum Consultant was no longer contracted to work with the Trust, and they had left the country.”
3 more stated actions in the Promises tab.
- 10 months later
Raised again · 1st time
Christopher Larsen↗
13 Jun 2024 · Isobel Thistlethwaite · Rutland and North Leicestershire
Closely relatedConfidence 0.90 · high“The Serious Incident Investigation into Mr [name redacted] death did uncover and accepted some failings in relation to the care provided to Mr [name redacted].”
Original on judiciary.uk ↗ Repeated from the earlier report:SeriousIncidentInvestigationcareprovided
Leicestershire Partnership NHS Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Leicestershire 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.
2023 → 2024Christopher Larsen10 months after Marie Zarins · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight inadequacies in the Trust's Serious Incident Investigation and Reporting processes. They differ in the specific cases examined (Miss [name redacted] vs Mr [name redacted]) and the particular aspects of the process criticised.
Marie Zarins · 14 Aug 2023
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
Original on judiciary.uk ↗ Christopher Larsen · 13 Jun 2024
“The Serious Incident Investigation into Mr [name redacted] death did uncover and accepted some failings in relation to the care provided to Mr [name redacted].”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”
Stated action
“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”
Stated action
“The Trust was unable to contact the Locum Consultant for input into the original SI investigation due to not holding the latest contact details; the Locum Consultant was no longer contracted to work with the Trust, and they had left the country.”
Stated action
“We confirm that prior to the MDT meeting, the Locum Consultant accessed SystmOne for a period of seven minutes. We also confirm that they did not raise any concerns regarding MDT meetings with the Clinical or Medical Director.”
Stated action
“We will provide further detail of this MDT meeting in our review of the initial SI report.”
Stated action
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
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 Leicestershire 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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.91 | 0.61 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Leicestershire Partnership 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.