Lack of continuous family engagement in patient care
Northumberland received 2 coroners' reports about this hazard between 6 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 Northumberland was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger”
Original on judiciary.uk ↗ No published response from Northumberland was found for this report.
- 1 year 5 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“- a continuous engagement with the family in the "triangle of care", including regular communication and updating life stories”
Original on judiciary.uk ↗ Northumberland responded, stating 1 specific action.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 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 → 2021Richard Burgess1 year 5 months after Maureen Wharton · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient involvement of family or social support in patient care. The earlier report notes a lack of enquiry to identify such support, while the later report stresses absent continuous engagement with the family.
Maureen Wharton · 6 Dec 2019
“No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger”
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 Northumberland 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.”
- 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 → 2021 | 0.63 | 0.01 | 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.