Staff unawareness of observation requirements
Norfolk and Suffolk NHS Foundation Trust received 2 coroners' reports about this hazard between 24 Dec 2015 and 22 Aug 2022.
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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient.”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗
“the ' Trust has decided to fully enclose the ramp. This work has commenced and is proposed to be completed by the end of March 2016”
Stated timescale: end of March 2016
“The Trust is taking this matter further than the Norfolk acute hospitals instructing. managers based in Suffolk to liaise with their acute hospital colleagues as well, Each area is working to create local protocols which will be incorporated into policy.”
- 6 years 8 months laterClosely relatedConfidence 0.92 · higha different coroner
“Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of [the deceased] in accordance with NSFT's Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly.”
Original on judiciary.uk ↗ Repeated from the earlier report:evidenceobservationsstaffcarry
Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse- in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. [name redacted] to this aspect the trust is formulating a seminar on shift co-ordination and”
Stated timescale: three months
- 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 → 2022Eliot Harris6 years 8 months after Christopher Higgins · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight that staff are not performing patient observations correctly due to lack of awareness or training. The later report adds that training and competency assessments are missing, building on the earlier concern about unclear observation requirements.
Christopher Higgins · 24 Dec 2015
“It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient.”
Original on judiciary.uk ↗ Eliot Harris · 22 Aug 2022
“Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of [the deceased] in accordance with NSFT's Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly.”
Original on judiciary.uk ↗
Stated action · timescale: end of March 2016
“the ' Trust has decided to fully enclose the ramp. This work has commenced and is proposed to be completed by the end of March 2016”
Stated action
“The Trust is taking this matter further than the Norfolk acute hospitals instructing. managers based in Suffolk to liaise with their acute hospital colleagues as well, Each area is working to create local protocols which will be incorporated into policy.”
Stated action · timescale: three months
“The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse- in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. [name redacted] to this aspect the trust is formulating a seminar on shift co-ordination and”
- 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 → 2022 | 0.66 | 0.22 | Closely related · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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
- Lack of formal mental health act assessment2 reports · 2019–2019
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.