Lack of care coordinator for continuity of support
Norfolk and Suffolk NHS Foundation Trust received 2 coroners' reports about this hazard between 16 Jan 2015 and 6 Aug 2015.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
No published response from Norfolk and Suffolk NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“On 12 August 2014 Psychiatrist recommended Mr [name redacted] would benefit from a Support Worker and/or Care Co-Ordinator - this was not actioned”
Original on judiciary.uk ↗ No published response from Norfolk and Suffolk NHS Foundation Trust was found for this report.
- 7 months laterClosely relatedConfidence 0.80 · moderate
“Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr [name redacted] death. Her Line Managers were aware of this continuous absence”
Original on judiciary.uk ↗ Repeated from the earlier report:CareCo-ordinator2014
Norfolk and Suffolk NHS Foundation Trust responded, stating 3 specific actions.Response (PDF) ↗
“The Trust recognises that changes in medication are a significant stage in an individual's treatman and require monitoring in order to ensure it is having anticipated effects and be ready to respond, to possible side effects.”
“the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts.”
1 more stated action in the Promises tab.
- All reports to Norfolk and Suffolk 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.
2015 → 2015Thomas Thurling7 months after Robert Anstice · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with the continuity and availability of a care coordinator/service for patients needing support.
Robert Anstice · 16 Jan 2015
“On 12 August 2014 Psychiatrist recommended Mr [name redacted] would benefit from a Support Worker and/or Care Co-Ordinator - this was not actioned”
Original on judiciary.uk ↗ Thomas Thurling · 6 Aug 2015
“Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr [name redacted] death. Her Line Managers were aware of this continuous absence”
Original on judiciary.uk ↗
No published response from Norfolk and Suffolk NHS Foundation Trust was found for this report.
Stated action
“The Trust recognises that changes in medication are a significant stage in an individual's treatman and require monitoring in order to ensure it is having anticipated effects and be ready to respond, to possible side effects.”
Stated action
“the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts.”
Stated action
“The Trust is taking active steps to recruit to these areas but we have found our experiences and challenges are shared across the health sector. The Trust is taking steps to mitigate the risks by employing temporary staffing for defined periods of time.”
- 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 Norfolk and Suffolk 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 |
|---|---|---|---|---|
| 2015 → 2015 | 0.62 | 0.13 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Norfolk and Suffolk NHS Foundation Trust
- Physical health check delays mental health referrals5 reports · 2014–2024
- Restricted access to treatment for borderline personality disorder2 reports · 2019–2024
- Inconsistent medication quantity documentation and unrecorded stock2 reports · 2017–2022
- Staff unawareness of observation requirements2 reports · 2015–2022
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.