Delayed x-ray result review and reporting
Plymouth Hospitals NHS Trust received 2 coroners' reports about this hazard between 9 Jun 2014 and 22 Sept 2015.
They came from 1 coroner 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
Original on judiciary.uk ↗ Plymouth Hospitals NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“We have made a number of changes to the handover process, both in relation to medical and nursing procedures.”
- 1 year 3 months laterClosely relatedConfidence 0.80 · moderate
“There was a delay of 5 days in the formal reporting of the original X-ray;”
Original on judiciary.uk ↗ Plymouth Hospitals NHS Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Plymouth Hospitals NHS 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.
2014 → 2015William Harnell1 year 3 months after Audrey Daws · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight delays in ensuring that X‑ray results are reviewed and formally reported in a timely manner. The earlier case notes a >24‑hour gap before staff saw the result, while the later case describes a five‑day delay in formal reporting.
Audrey Daws · 9 Jun 2014
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
Original on judiciary.uk ↗ William Harnell · 22 Sept 2015
“There was a delay of 5 days in the formal reporting of the original X-ray;”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have made a number of changes to the handover process, both in relation to medical and nursing procedures.”
Stated action
“We have made a number of changes to the handover process, both in relation to medical and nursing procedures.”
No specific action could be extracted with a verified quote.
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 Plymouth Hospitals NHS 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 |
|---|---|---|---|---|
| 2014 → 2015 | 0.81 | 0.08 | Closely related · 0.80 | 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.