Inadequate discharge planning processes
Oxford Health NHS Foundation Trust received 2 coroners' reports about this hazard between 12 Apr 2019 and 5 Jun 2025.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community.”
Original on judiciary.uk ↗ Oxford Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust is considering if plastic spoons can be replaced by an alternative product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is working with the matrons to identify if there is alternative cutlery available that may be more suitable for this patient group.”
Stated timescale: September 2019
- 6 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.”
Original on judiciary.uk ↗ Repeated from the earlier report:Planningdischargecommunity
Oxford Health NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Oxford Health 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.
2019 → 2025Cain Donald6 years 2 months after Emma Butler · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight weaknesses in the trust's discharge planning processes that could leave patients unsafe when leaving inpatient care. The earlier report cites unclear communication and risk review, while the later report notes missing family and agency involvement in discharge from a PICU.
Emma Butler · 12 Apr 2019
“Planning for discharge. The evidence indicated the move towards and importance of shorter periods of admission and planning for discharge into the community.”
Original on judiciary.uk ↗ Cain Donald · 5 Jun 2025
“Planning of discharge from detention under the Mental Health Act at Ashurst PICU directly into the community.”
Original on judiciary.uk ↗
Stated action · timescale: September 2019
“The Trust is considering if plastic spoons can be replaced by an alternative product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is working with the matrons to identify if there is alternative cutlery available that may be more suitable for this patient group.”
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 Oxford Health 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 |
|---|---|---|---|---|
| 2019 → 2025 | 0.75 | 0.29 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.