Recurring hazard (see the quoted concerns)
Camden and Islington NHS Foundation Trust received 2 coroners' reports about this hazard between 29 Apr 2015 and 23 Oct 2017.
They came from 1 coroner 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The doctor did not ask Ms [name redacted] about thoughts of suicide within the context of her earlier declaration that she would die that night.”
Original on judiciary.uk ↗ Camden and Islington NHS Foundation Trust responded.Response (PDF) ↗
- 2 years 6 months laterClosely relatedConfidence 0.90 · high
“There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.”
Original on judiciary.uk ↗ Camden and Islington NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”
Stated timescale: early 2018
- 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 → 2017Sian Witheridge2 years 6 months after Finnulla Martin · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight shortcomings in assessing suicide risk during mental health encounters.
Finnulla Martin · 29 Apr 2015
“The doctor did not ask Ms [name redacted] about thoughts of suicide within the context of her earlier declaration that she would die that night.”
Original on judiciary.uk ↗ Sian Witheridge · 23 Oct 2017
“There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Development of care Guidelines to be a a) June 2015-On_ | The set of guidelines and agreement guidelines relating to signed off at August track. The police patients brought into the 2015 ED Board and | Consultant in guidelines have _| (draft v3 attached)”
No specific action could be extracted with a verified quote.
Stated action · timescale: early 2018
“we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”
- 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 | 0.65 | 0.05 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Camden and Islington 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.