Lack of rolling risk assessment documentation in SystemOne
Birmingham and Solihull Mental Health Foundation received 2 coroners' reports about this hazard between 15 Mar 2023 and 2 Oct 2023.
They came from 2 different coroners. 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.
“No such facility is in use on SystemOne at HMP Birmingham.”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health Foundation responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“Matters of Concern: The absence of ongoing risk assessment documentation for patients with mental illness within SystmOne records at HMP Birmingham.”
“The Trust has begun a 3 month pilot which will ensure a Consultant [name redacted] attends the 3 MDT meetings at the Prison each week. The Secure Care and Offender Health Clinical Governance Committee (CGC) will review the outcomes for the pilot after 3 months, to ascertain if this is clinically beneficial to patients”
Stated timescale: 3 month pilot
- 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk.”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health Foundation responded.Response (PDF) ↗
- All reports to Birmingham and Solihull Mental Health Foundation
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 → 2023Paula Lenihan7 months after Jai Singh · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the completion and updating of risk assessments in mental health care, noting that inadequate documentation increases risk of harm.
Jai Singh · 15 Mar 2023
“No such facility is in use on SystemOne at HMP Birmingham.”
Original on judiciary.uk ↗ Paula Lenihan · 2 Oct 2023
“If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk.”
Original on judiciary.uk ↗
Stated action
“Matters of Concern: The absence of ongoing risk assessment documentation for patients with mental illness within SystmOne records at HMP Birmingham.”
Stated action · timescale: 3 month pilot
“The Trust has begun a 3 month pilot which will ensure a Consultant [name redacted] attends the 3 MDT meetings at the Prison each week. The Secure Care and Offender Health Clinical Governance Committee (CGC) will review the outcomes for the pilot after 3 months, to ascertain if this is clinically beneficial to patients”
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 Birmingham and Solihull Mental Health Foundation 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 → 2023 | 0.70 | 0.01 | 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.