Inconsistent medication quantity documentation and unrecorded stock
Norfolk and Suffolk NHS Foundation Trust received 2 coroners' reports about this hazard between 27 Feb 2017 and 26 Sept 2022.
They came from 2 different coroners 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a View to self-harm, is of obvious concern.”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
- 5 years 7 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded.Response (PDF) ↗
- 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.
2017 → 2022Lewis Begley5 years 7 months after Rachel Edwards · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with tracking medication quantities that could lead to overdose or misuse. The earlier report focuses on excessive discharge supplies; the later report notes missing records of stored medication.
Rachel Edwards · 27 Feb 2017
“Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a View to self-harm, is of obvious concern.”
Original on judiciary.uk ↗ Lewis Begley · 26 Sept 2022
“Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much”
Original on judiciary.uk ↗
Stated action
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
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 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 |
|---|---|---|---|---|
| 2017 → 2022 | 0.68 | 0.04 | Closely related · 0.80 | different |
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
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.