Lack of automated discharge medication notification to GP
Norfolk and Suffolk NHS Foundation Trust received 2 coroners' reports about this hazard between 27 Feb 2017 and 18 Mar 2019.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
- 2 years 1 month laterClosely relatedConfidence 0.85 · higha different coroner
“An initial full, updating letter was sent to [the deceased]'s GP. However no further updating information was sent.”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust is taking the following actions which are anticipated to assist in bringing consistent and sustained improvement. All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to drive improvement.”
- All reports to Norfolk and Suffolk 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 → 2019Ellie Long2 years 1 month after Rachel Edwards · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in reliably communicating medication or updating information from the trust to a patient's GP. The earlier report points to missing automated notifications, while the later report describes missed manual updates.
Rachel Edwards · 27 Feb 2017
“there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands”
Original on judiciary.uk ↗ Ellie Long · 18 Mar 2019
“An initial full, updating letter was sent to [the deceased]'s GP. However no further updating information was sent.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
Stated action
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
Stated action
“The Trust is taking the following actions which are anticipated to assist in bringing consistent and sustained improvement. All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to drive improvement.”
- 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 Norfolk and Suffolk 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 → 2019 | 0.68 | 0.05 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Norfolk and Suffolk NHS Foundation Trust
- Physical health check delays mental health referrals5 reports · 2014–2024
- Restricted access to treatment for borderline personality disorder2 reports · 2019–2024
- Inconsistent medication quantity documentation and unrecorded stock2 reports · 2017–2022
- Staff unawareness of observation requirements2 reports · 2015–2022
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.