Inadequate handover of clinical information between wards
General Medical Council received 2 coroners' reports about this hazard between 9 Oct 2018 and 31 Mar 2021.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from General Medical Council was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Original on judiciary.uk ↗ No published response from General Medical Council was found for this report.
- 2 years 6 months laterClosely relatedConfidence 0.85 · higha different coroner
“The inquest heard how there was no system of hand over when junior doctors change from ward to ward.”
Original on judiciary.uk ↗ General Medical Council responded, stating 1 specific action.Response (PDF) ↗
“Write to all UK Postgraduate Deans to request that they ensure their induction programmes for Foundation doctors are in protected time; include best practice; and, reinforce the requirements of Foundation Professional Capability 18: recognises and works within limits of personal competence;”
Stated timescale: 2021
- All reports to General Medical Council
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.
2018 → 2021Joan Coley2 years 6 months after Tom Cribley · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports identify problems with the handover of clinical information or competencies between staff members. The earlier report focuses on general clinical staff handovers, while the later report specifies a missing handover system for junior doctors moving between wards.
Tom Cribley · 9 Oct 2018
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Original on judiciary.uk ↗ Joan Coley · 31 Mar 2021
“The inquest heard how there was no system of hand over when junior doctors change from ward to ward.”
Original on judiciary.uk ↗
No published response from General Medical Council was found for this report.
Stated action · timescale: 2021
“Write to all UK Postgraduate Deans to request that they ensure their induction programmes for Foundation doctors are in protected time; include best practice; and, reinforce the requirements of Foundation Professional Capability 18: recognises and works within limits of personal competence;”
- 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 General Medical Council 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 |
|---|---|---|---|---|
| 2018 → 2021 | 0.79 | 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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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.