Lack of internal review and investigation shortcomings
Manchester Mental Health NHS Trust received 2 coroners' reports about this hazard between 19 Feb 2019 and 23 Dec 2019.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case”
Original on judiciary.uk ↗ Manchester Mental Health NHS Trust responded.Response (PDF) ↗
- 10 months laterClosely relatedConfidence 0.80 · moderate
“There were failures in the post death investigation process which may result In the true circumstances not being tdentified and steps taken to prevent continuation or recurrence of circumstances which may cause or contribute to a future death”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to Manchester Mental Health NHS 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.
2019 → 2019Kieran Hubbard10 months after Janice Keelan · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight shortcomings in the organisation's post‑death review processes. The earlier report notes a lack of internal review after a death, while the later report points to failures in the post‑death investigation that could prevent learning from incidents.
Janice Keelan · 19 Feb 2019
“It does not appear that following the death of the deceased, there has been any internal review or reflection by MCC about the processes involved in this case”
Original on judiciary.uk ↗ Kieran Hubbard · 23 Dec 2019
“There were failures in the post death investigation process which may result In the true circumstances not being tdentified and steps taken to prevent continuation or recurrence of circumstances which may cause or contribute to a future death”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No published response from Manchester Mental Health NHS Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Manchester Mental Health NHS 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 |
|---|---|---|---|---|
| 2019 → 2019 | 0.72 | 0.02 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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.