Risk assessment not updated with patient history
Oxford Health NHS Foundation Trust received 2 coroners' reports about this hazard between 21 Feb 2017 and 10 Jan 2025.
They came from 2 different coroners in 2 coroner areas. 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.
“they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr [name redacted] time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history”
Original on judiciary.uk ↗ Oxford Health NHS Foundation Trust responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The Governor, HMP Woodhill”
Stated timescale: 48 April 2017
“The section 17 leave form has been amended and is currently going through the Trust's governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017.”
Stated timescale: 28th April 2017
1 more stated action in the Promises tab.
- 7 years 11 months laterClosely relatedConfidence 0.92 · higha different coroner
“None of the records of contact with Mr [name redacted] completed by the AMHT in the period from August 2023 to the date of Mr [name redacted] death contained any written record of a risk assessment”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessment
Oxford Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire”
- All reports to Oxford Health 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.
2017 → 2025Jan Raciborski7 years 11 months after Jack Portland · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight problems with the documentation and updating of risk assessments for patients under care.
Jack Portland · 21 Feb 2017
“they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr [name redacted] time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history”
Original on judiciary.uk ↗ Jan Raciborski · 10 Jan 2025
“None of the records of contact with Mr [name redacted] completed by the AMHT in the period from August 2023 to the date of Mr [name redacted] death contained any written record of a risk assessment”
Original on judiciary.uk ↗
Stated action · timescale: 48 April 2017
“The Governor, HMP Woodhill”
Stated action · timescale: 28th April 2017
“The section 17 leave form has been amended and is currently going through the Trust's governance processes for approval. It is anticipated that use of the new form will be implemented no later than 28th April 2017.”
Stated action · timescale: 2016
“The Governor is confident that the increased focus on the training of staff on the requirements of the ACCT process, and the robust quality checks now in place, have led to a significant improvement in the quality, focus, and effectiveness of ACCT documents in supporting prisoners at risk of suicide and self-harm.”
Stated action
“and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire”
- 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 Oxford Health 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 |
|---|---|---|---|---|
| 2017 → 2025 | 0.67 | 0.02 | Closely related · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Oxford Health NHS Foundation Trust
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.