Inadequate inter-agency communication about risk and urgency
Department of Health and Social Care received 2 coroners' reports about this hazard between 20 Feb 2015 and 26 Apr 2021.
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.
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“The Ministry of Defence (MoD) has responsibility for the provision of primary care services for serving personnel. The MoD also provides additional mental health care for serving personnel delivered through fifteen military Departments of Community Mental Health (DCMHs) located in military centres in the UK, as well as centres overseas.”
Stated timescale: end of April 2015
- 6 years 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases”
Original on judiciary.uk ↗ Repeated from the earlier report:agenciesinformation
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making”
- All reports to Department of Health and Social Care
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.
2015 → 2021Alan Massam6 years 2 months after Richard Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight problems with sharing information between agencies regarding the level of risk and urgency of patient care. They concern the same hazard: inadequate inter‑agency communication about risk and urgency.
Richard Jones · 20 Feb 2015
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
Original on judiciary.uk ↗ Alan Massam · 26 Apr 2021
“there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
Stated action · timescale: end of April 2015
“The Ministry of Defence (MoD) has responsibility for the provision of primary care services for serving personnel. The MoD also provides additional mental health care for serving personnel delivered through fifteen military Departments of Community Mental Health (DCMHs) located in military centres in the UK, as well as centres overseas.”
No specific action could be extracted with a verified quote.
Stated action
“We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making”
- 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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2015 → 2021 | 0.74 | 0.23 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Department of Health and Social Care
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.