Inadequate incident reporting and review systems
Department of Health and Social Care received 2 coroners' reports about this hazard between 13 May 2024 and 12 May 2025.
They came from 1 coroner. 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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- 1 year laterClosely relatedConfidence 0.90 · high
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
Original on judiciary.uk ↗ Repeated from the earlier report:casetrust'sDatixincidentreportingsystem
Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2024 → 2025Kenneth Foster1 year after Elvon Morton · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that the trust's Datix incident reporting system, morbidity and mortality meeting process, and its safety investigation procedure were inadequate and operated in silos, preventing proper identification and learning from sub‑optimal practice.
Elvon Morton · 13 May 2024
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
Original on judiciary.uk ↗ Kenneth Foster · 12 May 2025
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.90 | 0.65 | Closely related · 0.90 | same |
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.