Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust received 2 coroners' reports about this hazard between 7 Jan 2020 and 5 Jun 2024.
They came from 2 different coroners. 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.
“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
Original on judiciary.uk ↗ County Durham and Darlington NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The root cause analysis report has been reviewed and we have concluded that a misleading choice of words have been used as follows:”
- 4 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient's medical records in such a way that relevant information is visible to those involved in care.”
Original on judiciary.uk ↗ County Durham and Darlington NHS Foundation Trust responded.Response (PDF) ↗
- All reports to County Durham and Darlington 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.
2020 → 2024Gillian Peacock4 years 5 months after Agnes Sansom · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that the trust's patient record system fails to make important clinical information readily visible to staff who need it. The earlier report focuses on untimely delivery of urgent information, while the later report stresses that recorded information is not accessible despite being present.
Agnes Sansom · 7 Jan 2020
“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
Original on judiciary.uk ↗ Gillian Peacock · 5 Jun 2024
“The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient's medical records in such a way that relevant information is visible to those involved in care.”
Original on judiciary.uk ↗
Stated action
“The root cause analysis report has been reviewed and we have concluded that a misleading choice of words have been used as follows:”
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 County Durham and Darlington 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 |
|---|---|---|---|---|
| 2020 → 2024 | 0.83 | 0.10 | 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.