Inadequate documentation hindering clinical communication
Closely relatedConfidence 0.80 · moderateHow sure the judge model was that the two concerns are the same hazard, from 0 to 1. Links below 0.70 are never shown. High is 0.85 or more. A chain is only as strong as its weakest link, so the chain shows the lowest confidence of any of its links.2 reports · 2017–2019 One-page brief (print or PDF)
Tameside General Hospital received 2 coroners' reports about this hazard between 21 Dec 2017 and 10 Jan 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 7 specific actions.
“The documentation held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.”
Tameside General Hospital responded, stating 1 specific action.Response (PDF) ↗
“We would hope that once you have had a chance to consider this further information with respect to documentation within the ED Department you will be reassured that there is clear evidence that there is nota cultural acceptance of poor documentation with the ED Department and that the department, particularly the Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to documentation and where these expectations are not met, that action is taken”
“The ward was staffed by ward doctors throughout the day but there was no documeniation to suggest communication between the ward doctors and nursing staff in relation to Mr [name redacted] and his deteriorating picture”
Tameside General Hospital responded, stating 6 specific actions.Response (PDF) ↗
“the Matron for theatres has met with and provided feedback to the individual staff members involved in the post-operative recovery period with respect to completing the appropriate documentation.”
“the Matron for theatres has taken measures to improve communication with ward staff, by introducing a formal telephone handover for patients identified as 'high risk' detailing the current NEWS score and management plan in place.”
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. Every quote shown was checked by code to appear word for word in the original report.
2017 → 2019Michael Flynn1 year 1 month after Margaret Postill · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderate
Both reports highlight inadequate documentation that hindered proper clinical communication and decision‑making.
Margaret Postill · 21 Dec 2017
“The documentation held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.”
“The ward was staffed by ward doctors throughout the day but there was no documeniation to suggest communication between the ward doctors and nursing staff in relation to Mr [name redacted] and his deteriorating picture”
Stated action in the response to the earlier report
“We would hope that once you have had a chance to consider this further information with respect to documentation within the ED Department you will be reassured that there is clear evidence that there is nota cultural acceptance of poor documentation with the ED Department and that the department, particularly the Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to documentation and where these expectations are not met, that action is taken”
“We would hope that once you have had a chance to consider this further information with respect to documentation within the ED Department you will be reassured that there is clear evidence that there is nota cultural acceptance of poor documentation with the ED Department and that the department, particularly the Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to documentation and where these expectations are not met, that action is taken”
“the Matron for theatres has met with and provided feedback to the individual staff members involved in the post-operative recovery period with respect to completing the appropriate documentation.”
Stated action
“the Matron for theatres has taken measures to improve communication with ward staff, by introducing a formal telephone handover for patients identified as 'high risk' detailing the current NEWS score and management plan in place.”
Stated action
“The Matron for Theatres has also provided assurances that an audit of recovery documentation has been commissioned to provide evidence of compliance and continuous monitoring.”
Stated action
“The Matron for the Orthopaedic Unit has provided assurances that formal discussions have taken place with the nursing staff identified through our investigation as failing to comply with Trust Policy in respect to the regularity, recording and appropriate escalation of NEWS observations, and consideration given to identified support or training needs.”
Stated action
“The Matron for the Orthopaedic Unit has advised that the learning from our investigation into the care provided to Mr. [name redacted] was shared and discussed at the Divisional Senior Nurses meeting and subsequently, has been raised again on receipt of your Se areng the Consultant [name redacted] who ied the Trust investigation, has provided his assurances that the case has also been raised and discussed at the Orthopaedic Speciality meeting, which is attended by all grades of Orthopaedic medical”
Stated action
“the Trust Patient Safety Team have drafted and distributed a 'Time out for Learning' bulletin focusing on the importance of completing, recording and escalating NEWS observations appropriately.”
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 Tameside General Hospital 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 TF-IDF compares shared words. Embedding compares meaning. Judge is the Nemotron Super verdict that decides whether a link is shown.
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.