Absence of structured care plans for high-risk patients
Central and North West London NHS Foundation Trust received 2 coroners' reports about this hazard between 19 Feb 2014 and 27 Nov 2016.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Central and North West London NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“formal, written care plan should be provided to the distant residential home”
Original on judiciary.uk ↗ No published response from Central and North West London NHS Foundation Trust was found for this report.
- 2 years 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The preparation of structured care plans for each patient.”
Original on judiciary.uk ↗ Central and North West London NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“prescriber is responsible for ensuring the ongoing monitorin effectiveness of medication, including side effects (GPs and CNWL Psychiatrists/ NMP). This is supported through: e In-line with community equivalence the GP would continue with repeat prescribing but would ensure the treatment plan assures them that the patient is in receipt of the appropriate level of supervision via primary care services. However, should the GP have any concerns around ongoing monitoring or psychological”
- All reports to Central and North West London 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.
2014 → 2016Matthew Russell2 years 9 months after Simon McAndrew · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports identify a deficiency in providing formal, written or structured care plans for patients receiving services outside the main hospital setting.
Simon McAndrew · 19 Feb 2014
“formal, written care plan should be provided to the distant residential home”
Original on judiciary.uk ↗ Matthew Russell · 27 Nov 2016
“The preparation of structured care plans for each patient.”
Original on judiciary.uk ↗
No published response from Central and North West London NHS Foundation Trust was found for this report.
Stated action
“prescriber is responsible for ensuring the ongoing monitorin effectiveness of medication, including side effects (GPs and CNWL Psychiatrists/ NMP). This is supported through: e In-line with community equivalence the GP would continue with repeat prescribing but would ensure the treatment plan assures them that the patient is in receipt of the appropriate level of supervision via primary care services. However, should the GP have any concerns around ongoing monitoring or psychological”
- 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 Central and North West London 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 |
|---|---|---|---|---|
| 2014 → 2016 | 0.73 | 0.38 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Central and North West London 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.