Incomplete care plan and risk assessment documentation
Sussex Partnership NHS Trust received 3 coroners' reports about this hazard between 21 Aug 2013 and 4 Jul 2017.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
Original on judiciary.uk ↗ Sussex Partnership NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”
- 2 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
Original on judiciary.uk ↗ No published response from Sussex Partnership NHS Trust was found for this report.
- 1 year 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory.”
Original on judiciary.uk ↗ Repeated from the earlier report:riskcareplans
Sussex Partnership NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“the Trust announced that it is planning to cease PEG insertion at the QVH site, initially on a 6-month trial basis, in order to consider the impact on patients.”
Stated timescale: 6-month trial basis
- All reports to Sussex 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.
2013 → 2015Brian Shillinglaw2 years 3 months after John Walker · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight shortcomings in the creation, updating, and communication of risk assessment and care planning documents. They differ in that the earlier report focuses on insufficient depth and lack of review, while the later report stresses the need for proper amendment, updating, and multidisciplinary communication.
John Walker · 21 Aug 2013
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
Original on judiciary.uk ↗ Brian Shillinglaw · 6 Nov 2015
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”
2015 → 2017Janet Muller1 year 8 months after Brian Shillinglaw · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the quality and completeness of care plan and risk assessment documentation.
Brian Shillinglaw · 6 Nov 2015
“The creation of Care Plan, Risk Assessment and other admission | documentation (2) The amending and updating of these plans”
Original on judiciary.uk ↗ Janet Muller · 4 Jul 2017
“Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory.”
Original on judiciary.uk ↗
Stated action
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”
No published response from Sussex Partnership NHS Trust was found for this report.
Stated action · timescale: 6-month trial basis
“the Trust announced that it is planning to cease PEG insertion at the QVH site, initially on a 6-month trial basis, in order to consider the impact on patients.”
- 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 Sussex 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 |
|---|---|---|---|---|
| 2013 → 2015 | 0.72 | 0.11 | Closely related · 0.90 | different |
| 2015 → 2017 | 0.69 | 0.05 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Sussex 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.