Inadequate clinical records hinder investigations
Department of Health and Social Care received 3 coroners' reports about this hazard between 5 Oct 2023 and 4 Jul 2024.
They came from 1 coroner. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 9 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The poor quality of recording clinical records impeded the Trust's governance processes”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“all patients at risk of falls should have an up-to-date Enhanced Care Assessment which should be discussed at the multi-disciplinary meetings and of which the nurse in charge should be aware”
- 0 months later
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 6 specific actions.Response (PDF) ↗
“seriously and has taken positive action to address those issues. To improve standards, an internal alert and a screen saver has been shared with staff which details good record keeping standards that should be adhered to by all staff as well as a video which has been developed with the Medical Director explaining the importance of good record keeping.”
“1 The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses. The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure”
4 more stated actions in the Promises tab.
- 8 months laterIdentical hazardConfidence 0.90 · high
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation”
Original on judiciary.uk ↗ Repeated from the earlier report:clinicalrecordspoorstandardimpededinvestigation
Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The CQC has confirmed that they are reviewing this case, and will consider what further action should be taken, and whether any monitoring of the trust, or regulatory response, is required.”
“be able to check the wording in their specific product information to ensure the appropriate advice on checking for leaks is present.”
- 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.
2023 → 2024David Morris8 months after Thomas Doyle · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that poor-quality or missing clinical records hindered investigations into patient deaths.
Thomas Doyle · 20 Oct 2023
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation”
Original on judiciary.uk ↗ David Morris · 4 Jul 2024
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
2023 → 2024David Morris9 months after Iris Fordham · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that inadequate or missing clinical records hindered the trust's ability to investigate deaths and carry out governance functions.
Iris Fordham · 5 Oct 2023
“The poor quality of recording clinical records impeded the Trust's governance processes”
Original on judiciary.uk ↗ David Morris · 4 Jul 2024
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Original on judiciary.uk ↗
Stated action
“all patients at risk of falls should have an up-to-date Enhanced Care Assessment which should be discussed at the multi-disciplinary meetings and of which the nurse in charge should be aware”
Stated action
“seriously and has taken positive action to address those issues. To improve standards, an internal alert and a screen saver has been shared with staff which details good record keeping standards that should be adhered to by all staff as well as a video which has been developed with the Medical Director explaining the importance of good record keeping.”
Stated action
“1 The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses. The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure”
Stated action
“Monthly audit of this takes place with the latest results showing 100% compliance of the records audited.”
Stated action
“1 The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses. The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure”
Stated action · timescale: every two months
“Structured review of individual sepsis mortalities is completed internally in the Trust using defined criteria. A presentation of both external and internal reviews is made to the Sepsis Steering Committee every two months.”
Stated action
“the Trust advises that there had been a number of significant improvements since the incident occurred. Sepsis screening in the Emergency Departments has significantly improved (evidenced by audit data). The Emergency Departments now use an electronic record, Careflow, which amongst several mandatory fields has a mandatory question with respect to consideration of sepsis.”
Stated action
“The CQC has confirmed that they are reviewing this case, and will consider what further action should be taken, and whether any monitoring of the trust, or regulatory response, is required.”
Stated action
“be able to check the wording in their specific product information to ensure the appropriate advice on checking for leaks is present.”
- 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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.78 | 0.40 | Identical · 0.90 | same |
| 2023 → 2024 | 0.75 | 0.39 | Identical · 0.90 | same |
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.