Insufficient family involvement in mental health care processes
Department of Health and Social Care received 2 coroners' reports about this hazard between 13 Dec 2019 and 19 May 2021.
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 Department of Health and Social Care was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“There was no clear policy about how a family could be effectively engaged by the CMHT;”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 1 year 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“- a continuous engagement with the family in the "triangle of care", including regular communication and updating life stories;”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”
Stated timescale: 27 July 2021
- All reports to Department of Health and Social Care
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.
2019 → 2021Richard Burgess1 year 5 months after Steven Marsland · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient involvement of families in mental health care processes.
Steven Marsland · 13 Dec 2019
“There was no clear policy about how a family could be effectively engaged by the CMHT;”
Original on judiciary.uk ↗ Richard Burgess · 19 May 2021
“- a continuous engagement with the family in the "triangle of care", including regular communication and updating life stories;”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
Stated action · timescale: 27 July 2021
“the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2019 → 2021 | 0.79 | 0.18 | Closely related · 0.90 | 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.