Inadequate documentation of clinical decisions
Barts Health NHS Trust received 2 coroners' reports about this hazard between 6 Feb 2017 and 13 May 2024.
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 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It seems clear that a decision was made to transfer Mrs [name redacted] from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“I am R Brittain, Assistant Coroner for Inner London North.”
Stated timescale: 3 April 2017
- 7 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“The decision to sedate Mr [name redacted] was flawed. The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”
Web search (Tavily): No evidence found either way
Key documents - Barts Health NHS Trust ↗“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”
4 more stated actions in the Promises tab.
- All reports to Barts 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.
2017 → 2024Elvon Morton7 years 3 months after Nuala Seddon · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that inadequate documentation of clinical decisions hinders proper scrutiny and increases risk of unsafe patient care. The earlier case concerns a possible non‑clinical transfer decision; the later case concerns a sedation decision, each suffering from missing records.
Nuala Seddon · 6 Feb 2017
“It seems clear that a decision was made to transfer Mrs [name redacted] from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff.”
Original on judiciary.uk ↗ Elvon Morton · 13 May 2024
“The decision to sedate Mr [name redacted] was flawed. The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
Original on judiciary.uk ↗
Stated action · timescale: 3 April 2017
“I am R Brittain, Assistant Coroner for Inner London North.”
Stated action
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”
What happened next: No evidence found either way
No evidence was found regarding the promised induction programme for A&E staff covering mental capacity act, documentation, sedation and escalation.
“Contrast: [](/)”
No evidence found does not mean the action did not happen.
Stated action
“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”
Stated action
“Teams will ensure that consultants on call confirm that they have remote access to the electronic healthcare record, this will eliminate the risk that documentation is not completed in relation to critical decisions.”
Stated action
“The Trust are supportive of staff that are increasingly managing high numbers of complex and acutely unwell patients. In this case, doctors sought and were provided with advice from a consultant on call. The consultant on call will attend to perform certain procedures (in line with the Royal College of Emergency Medicine guidance).”
Stated action
“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”
Stated action
“WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests.”
No specific action could be extracted with a verified quote.
- 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 Barts 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 |
|---|---|---|---|---|
| 2017 → 2024 | 0.66 | 0.08 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Barts Health NHS Trust
- Lack of transport suitability assessment for changing patient conditions2 reports · 2020–2026
- Governance failure in incident identification and poor quality of clinical notes3 reports · 2023–2025
- Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED3 reports · 2024–2025
- Lack of strategic governance hindering incident identification2 reports · 2023–2025
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.