Recurring hazard (see the quoted concerns)
Medicines and Healthcare products Regulatory Agency received 2 coroners' reports about this hazard between 11 Jul 2014 and 4 Jul 2024.
They came from 2 different coroners 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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The recognition and treatment of sepsis as per national guidelines”
Original on judiciary.uk ↗ Medicines and Healthcare products Regulatory Agency responded.Response (PDF) ↗
- 10 years laterIdentical hazardConfidence 0.90 · higha different coroner
“During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr [name redacted] gastrostomy leak and the onset of sepsis.”
Original on judiciary.uk ↗ Medicines and Healthcare products Regulatory Agency 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 Medicines and Healthcare products Regulatory Agency
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 → 2024David Morris10 years after Maria Lopes · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight failures in recognizing and treating sepsis according to national guidelines.
Maria Lopes · 11 Jul 2014
“The recognition and treatment of sepsis as per national guidelines”
Original on judiciary.uk ↗ David Morris · 4 Jul 2024
“During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr [name redacted] gastrostomy leak and the onset of sepsis.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
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 Medicines and Healthcare products Regulatory Agency 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 → 2024 | 0.66 | 0.12 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Medicines and Healthcare products Regulatory Agency
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.