Reliance on informal assurances leading to missed referrals
Pennine Care NHS Trust received 3 coroners' reports about this hazard between 18 Mar 2014 and 30 Nov 2017.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“That the GP felt it was sufficient for him to simply discuss the deceased's care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process.”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded.Response (PDF) ↗
- 2 years 11 months later
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded.Response (PDF) ↗
- 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made.”
Original on judiciary.uk ↗ Repeated from the earlier report:completedreferral
Pennine Care NHS Trust responded.Response (PDF) ↗
- All reports to Pennine Care NHS 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 → 2017Lindsey Hassall9 months after Thomas Green · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in the transfer of referral information between general practitioners and mental health services, leading to missed follow‑up care.
Thomas Green · 16 Feb 2017
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
Original on judiciary.uk ↗ Lindsey Hassall · 30 Nov 2017
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The CCG will work with PCFT and GPs to review and establish clear pathways into MH support for people with complex needs. This will identify any gaps which will be taken forward within commissioning intentions. We have commenced this work already and aim to conclude it within four months.”
2014 → 2017Lindsey Hassall3 years 8 months after David Chatburn · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that the GP did not make a formal referral because they believed a referral had already been arranged through informal communication or an assumed action. The core hazard is the reliance on non‑formal assurances leading to missed referrals.
David Chatburn · 18 Mar 2014
“That the GP felt it was sufficient for him to simply discuss the deceased's care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process.”
Original on judiciary.uk ↗ Lindsey Hassall · 30 Nov 2017
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Pennine Care NHS 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 → 2017 | 0.78 | 0.11 | Closely related · 0.90 | different |
| 2014 → 2017 | 0.71 | 0.13 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.