Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust received 4 coroners' reports about this hazard between 17 Jul 2014 and 4 Mar 2024.
They came from 3 different coroners in 2 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 9 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The evidence was that Mr [name redacted] lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr [name redacted] did not wish information about him to be shared.”
Original on judiciary.uk ↗ Kent and Medway NHS and Social Care Partnership Trust responded.Response (PDF) ↗
- 1 year 6 months later
“Carers were not advised about any behaviours that might indicate an increased risk”
Original on judiciary.uk ↗ Kent and Medway NHS and Social Care Partnership Trust responded, stating 4 specific actions.Response (PDF) ↗
“the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”
Stated timescale: February 2016
“The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care”
Stated timescale: ongoing
2 more stated actions in the Promises tab.
- 6 years 8 months later
“Carer breakdown is likely to have increased the risks of suicidality on discharge as this was not addressed during the hospital admission nor on discharge”
Original on judiciary.uk ↗ No published response from Kent and Medway NHS and Social Care Partnership Trust was found for this report.
- 1 year 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health”
Original on judiciary.uk ↗ Kent and Medway NHS and Social Care Partnership Trust responded, stating 5 specific actions.Response (PDF) ↗
“Staff should record their handover to the enhanced care nurse to explain the risks to harm if they are not present.”
“Once admitted to the ward, staff should seek to understand if patients admitted following overdose have any remaining medication at home, and if so, what quantity.”
3 more stated actions in the Promises tab.
- All reports to Kent and Medway NHS and Social Care Partnership 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.
2022 → 2024Sarah Keen1 year 5 months after Robert Brown · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that carers were not given essential information about the patient’s mental‑health risks and medication situation. This lack of information prevented carers from recognising and responding to the patient’s suicidal intent.
Robert Brown · 20 Sept 2022
“Carer breakdown is likely to have increased the risks of suicidality on discharge as this was not addressed during the hospital admission nor on discharge”
Original on judiciary.uk ↗ Sarah Keen · 4 Mar 2024
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health”
Original on judiciary.uk ↗ 2014 → 2024Sarah Keen9 years 8 months after Joshua Brown · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that caregivers or family members were not given essential information about the patient's condition, treatment, or risks, which hindered their ability to provide safe support. The core issue is inadequate information sharing leading to potential harm.
Joshua Brown · 17 Jul 2014
“The evidence was that Mr [name redacted] lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr [name redacted] did not wish information about him to be shared.”
Original on judiciary.uk ↗ Sarah Keen · 4 Mar 2024
“The enhanced carer had not been told the reason that she was providing one to one care for [the deceased], was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm including by overdosing on prescribed medications.”
Original on judiciary.uk ↗ 2016 → 2024Sarah Keen8 years 1 month after Joanna Bowring · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that carers were not given essential information about risks of self‑harm or suicide that would enable them to recognise warning signs.
Joanna Bowring · 27 Jan 2016
“Carers were not advised about any behaviours that might indicate an increased risk”
Original on judiciary.uk ↗ Sarah Keen · 4 Mar 2024
“was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for”
No specific action could be extracted with a verified quote.
Stated action · timescale: February 2016
“the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”
Stated action · timescale: ongoing
“The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care”
Stated action · timescale: February 2016
“The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for”
Stated action · timescale: June 2016
“The Service Line is to commission an external Risk Assessment Training company (STORM) to deliver Nationally Recommended Risk Assessment Training Trainors to key individuals”
No published response from Kent and Medway NHS and Social Care Partnership Trust was found for this report.
Stated action
“Staff should record their handover to the enhanced care nurse to explain the risks to harm if they are not present.”
Stated action
“Once admitted to the ward, staff should seek to understand if patients admitted following overdose have any remaining medication at home, and if so, what quantity.”
Stated action
“The discharge notification should indicate that a reduced amount of medication has been prescribed and the reason for this recorded.”
Stated action
“A reminder to staff in both organisations has been circulated through Trust wide communications in regard to the use of abbreviations in patient records.”
Stated action
“Consider monthly interface meeting with agenda to include potential risk spots, developing shared learning and practice changes and building a culture of collaboration.”
- 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 Kent and Medway NHS and Social Care Partnership 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 |
|---|---|---|---|---|
| 2022 → 2024 | 0.64 | 0.09 | Closely related · 0.90 | different |
| 2014 → 2024 | 0.65 | 0.06 | Closely related · 0.90 | different |
| 2016 → 2024 | 0.67 | 0.00 | 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.