Discharge without family involvement in planning
Northumberland received 4 coroners' reports about this hazard between 29 Oct 2019 and 7 Jun 2023.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 2 of the 3 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“[the deceased] was discharged despite there being no input from those to whose care she was being entrusted.”
Original on judiciary.uk ↗ Northumberland responded.Response (PDF) ↗
- 3 years 3 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Comprehensive planning for home leave and discharge from hospital was not evident, including contingency planning and the involvement of the family.”
Original on judiciary.uk ↗ Northumberland responded.Response (PDF) ↗
- 3 months later
Raised again · 2nd time
Odessa Carey↗
12 May 2023 · Andrew Hetherington · North Northumberland and South Northumberland
Closely relatedConfidence 0.80 · moderatea different coroner“I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.”
Original on judiciary.uk ↗ Repeated from the earlier report:dischargetreatmentteam
No published response from Northumberland was found for this report.
- 1 month laterClosely relatedConfidence 0.85 · high
“[the deceased] was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be,”
Original on judiciary.uk ↗ Repeated from the earlier report:dischargeddespite
Northumberland responded, stating 3 specific actions.Response (PDF) ↗
“Discharge processes to be reviewed by Hadrian Ward to ensure onward referrals are communicated with receiving teams”
Stated timescale: 5 April 2023
“For the team to continue monitoring and assurance of care giver inclusion in safety planning and discharge planning”
Stated timescale: May 2023 audit, August repeat
1 more stated action in the Promises tab.
- All reports to Northumberland
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 → 2023Daniel Futers3 years 3 months after Charlotte Grace · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient discharge planning that fails to involve the patient's family or the team taking over care.
Charlotte Grace · 29 Oct 2019
“(1) [the deceased] was discharged despite there being no input from those to whose care she was being entrusted.”
Original on judiciary.uk ↗ Daniel Futers · 2 Feb 2023
“Comprehensive planning for home leave and discharge from hospital was not evident, including contingency planning and the involvement of the family.”
Original on judiciary.uk ↗ 2019 → 2023Odessa Carey3 years 6 months after Charlotte Grace · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in the discharge planning process where key teams or professionals were not adequately involved.
Charlotte Grace · 29 Oct 2019
“a gentleman hanged himself 2 days after a discharge from the Carleton Clinic when again the Home Treatment Team were expected to take over but not invited to the discharge meeting”
Original on judiciary.uk ↗ Odessa Carey · 12 May 2023
“I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator.”
Original on judiciary.uk ↗ 2019 → 2023Brenda Shields3 years 7 months after Charlotte Grace · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports note that families or carers were not involved in the discharge process despite expectations that they should be. They differ in the specific service involved (Carleton Clinic/Home Treatment Team vs Hadrian unit/Crisis team) and include additional issues such as delayed GP notification.
Charlotte Grace · 29 Oct 2019
“[the deceased] was discharged despite there being no input from those to whose care she was being entrusted.”
Original on judiciary.uk ↗ Brenda Shields · 7 Jun 2023
“[the deceased] was discharged without any planned follow up. Her family were not involved in the discharge process despite assurances that they would be,”
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 published response from Northumberland was found for this report.
Stated action · timescale: 5 April 2023
“Discharge processes to be reviewed by Hadrian Ward to ensure onward referrals are communicated with receiving teams”
Stated action · timescale: May 2023 audit, August repeat
“For the team to continue monitoring and assurance of care giver inclusion in safety planning and discharge planning”
Stated action · timescale: 80% across service currently
“Carer leads continue to roll out carer awareness training”
- 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 Northumberland 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 → 2023 | 0.68 | 0.11 | Closely related · 0.80 | different |
| 2019 → 2023 | 0.73 | 0.19 | Closely related · 0.80 | different |
| 2019 → 2023 | 0.71 | 0.09 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Northumberland
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.