Delayed mental health assessment in emergency unit
Camden and Islington NHS Foundation Trust received 2 coroners' reports about this hazard between 12 Nov 2015 and 24 Aug 2017.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Most importantly, [name redacted] waited four hours in the emergency unit before he saw a mental healthcare professional for the first time.”
Original on judiciary.uk ↗ Camden and Islington NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
- 1 year 9 months laterClosely relatedConfidence 0.85 · high
“Mr [name redacted] waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.”
Original on judiciary.uk ↗ Repeated from the earlier report:waitedemergencyunithours
Camden and Islington NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“we have asked to be provided with copies of CANDI's finalised Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately”
“The nurse in question was an agency professional, employed by NHS Professionals. (NHSP). tn light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed.”
Stated timescale: November
- All reports to Camden and Islington 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.
2015 → 2017Jonathan Meaney1 year 9 months after Matthew Groom · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports describe long waits in the emergency unit leading to delayed mental health assessment and risk of premature discharge.
Matthew Groom · 12 Nov 2015
“Most importantly, [name redacted] waited four hours in the emergency unit before he saw a mental healthcare professional for the first time.”
Original on judiciary.uk ↗ Jonathan Meaney · 24 Aug 2017
“Mr [name redacted] waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Stated action
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Stated action
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Stated action
“we have asked to be provided with copies of CANDI's finalised Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately”
Stated action · timescale: November
“The nurse in question was an agency professional, employed by NHS Professionals. (NHSP). tn light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed.”
- 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 Camden and Islington 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 |
|---|---|---|---|---|
| 2015 → 2017 | 0.72 | 0.21 | Closely related · 0.85 | same |
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.