Inadequate supervision of care coordinator role
Oxford Health NHS Foundation Trust received 2 coroners' reports about this hazard between 9 May 2018 and 25 Nov 2024.
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 Oxford Health NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness.”
Original on judiciary.uk ↗ No published response from Oxford Health NHS Foundation Trust was found for this report.
- 6 years 7 months laterClosely relatedConfidence 0.85 · higha different coroner
“no care co- ordinator or key worker was provided to [name redacted] after her discharge from hospital on 7th of September 2022.”
Original on judiciary.uk ↗ Oxford Health NHS Foundation Trust responded, stating 3 specific actions.Response (PDF) ↗
“The Trust's initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from [name redacted]'s death.”
Stated timescale: January 2025
“secondary care services have access to a system called Thames Valley & Surrey (TVS) Shared Care Records/Graphnet, to which system BTT has uploaded patient information dating back to 1st May 2022. This upload concluded in November 2024.”
Stated timescale: November 2024
1 more stated action in the Promises tab.
- 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.
2018 → 2024Jaipreet Panesar6 years 7 months after Lewis Colgan · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with the care coordinator role – one cites inadequate supervision of that role, the other notes the complete absence of a care coordinator after discharge.
Lewis Colgan · 9 May 2018
“supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness.”
Original on judiciary.uk ↗ Jaipreet Panesar · 25 Nov 2024
“no care co- ordinator or key worker was provided to [name redacted] after her discharge from hospital on 7th of September 2022.”
Original on judiciary.uk ↗
No published response from Oxford Health NHS Foundation Trust was found for this report.
Stated action · timescale: January 2025
“The Trust's initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from [name redacted]'s death.”
Stated action · timescale: November 2024
“secondary care services have access to a system called Thames Valley & Surrey (TVS) Shared Care Records/Graphnet, to which system BTT has uploaded patient information dating back to 1st May 2022. This upload concluded in November 2024.”
Stated action · timescale: 12th December 2024
“guidance on the use of Thames Valley & Surrey Shared Care Records and this guidance was most recently updated on 12th December 2024.”
- 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 |
|---|---|---|---|---|
| 2018 → 2024 | 0.69 | 0.02 | 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.