Inadequate multidisciplinary team meetings
Midlands Partnership NHS Foundation Trust received 2 coroners' reports about this hazard between 13 Nov 2018 and 22 Feb 2024.
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 8 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It is apparent that patients do benefit from regular 'ward rounds' or 'multi- disciplinary team meetings' (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings.”
Original on judiciary.uk ↗ Midlands Partnership NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated timescale: 8 January 2019
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
- 5 years 3 months later
Raised again · 1st time
Jamie Pilkington↗
22 Feb 2024 · Andrew Barkley · Staffordshire and Stoke on Trent
Closely relatedConfidence 0.90 · higha different coroner“There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.”
Original on judiciary.uk ↗ Repeated from the earlier report:MultiDisciplinaryTeam
Midlands Partnership NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗
“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”
Stated timescale: December 2023
“When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide”
Stated timescale: December 2023
4 more stated actions in the Promises tab.
- All reports to Midlands Partnership 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.
2018 → 2024Jamie Pilkington5 years 3 months after Thomas Jackson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the multidisciplinary team process: the earlier report notes poor conduct and preparation of ward rounds/MDT meetings, while the later report notes a lack of clear next steps, timescales, and scheduled discussion of a patient’s case with the MDT.
Thomas Jackson · 13 Nov 2018
“It is apparent that patients do benefit from regular 'ward rounds' or 'multi- disciplinary team meetings' (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings.”
Original on judiciary.uk ↗ Jamie Pilkington · 22 Feb 2024
“There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team.”
Original on judiciary.uk ↗
Stated action · timescale: 8 January 2019
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated action
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
Stated action · timescale: December 2023
“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”
Stated action · timescale: December 2023
“When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide”
Stated action · timescale: December 2023
“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”
What happened next: No evidence found either way
The trust's patient safety plan outlines a process for discussing risk factors and developing safety plans collaboratively, but no specific timeline for implementation is provided in the document.
“Patient safety incident response plan Summary This plan describes how the trust will respond to patient safety incidents, in accordance with the Patient Safety Incident Response Framework (PSIRF) and national reporting requirements.”
No evidence found does not mean the action did not happen.
Stated action · timescale: Ongoing
“The Overcoming Challenging Times plan is collaborative in nature, designed to enable the service user to identify changes in behaviours, risk and thought processes and empowers them to engage in activities that have previously proven effective in supporting them to manage their emotions and related risks”
Stated action · timescale: Ongoing
“Family and carer engagement; ensuring that families and carers are included in safety planning”
Stated action · timescale: Ongoing
“Monitoring; engagement in real time suicide surveillance, patient safety incident review and learning from deaths process”
- 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 Midlands Partnership 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 |
|---|---|---|---|---|
| 2018 → 2024 | 0.63 | 0.09 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Midlands Partnership 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.