Abdominal pain pathway lacks clear discriminatory criteria
NHS England received 2 coroners' reports about this hazard between 4 Oct 2021 and 30 Sept 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 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
Original on judiciary.uk ↗ NHS England responded, stating 6 specific actions.Response (PDF) ↗
“Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken: 1. Work has been undertaken on a focused area of learning known as a”
Stated timescale: October 2021
“Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability.”
4 more stated actions in the Promises tab.
- 3 years laterClosely relatedConfidence 0.90 · higha different coroner
“The inquest also examined East Kent Hospital's Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented”
Original on judiciary.uk ↗ Repeated from the earlier report:AbdominalPainPathway
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
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.
2021 → 2024Megan Williams3 years after Hannah Royle · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify shortcomings in the abdominal pain clinical pathway, noting it is not robust or clear enough for clinicians to manage varied symptoms.
Hannah Royle · 4 Oct 2021
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
Original on judiciary.uk ↗ Megan Williams · 30 Sept 2024
“The inquest also examined East Kent Hospital's Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented”
Original on judiciary.uk ↗
Stated action · timescale: October 2021
“Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken: 1. Work has been undertaken on a focused area of learning known as a”
Stated action
“Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability.”
Stated action
“The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.”
Stated action · timescale: January 2022
“Our Head of Governance for 111 plans to publish a shared learning based on [the deceased]'s family's contacts with the 111 service before the end of January 2022.”
Stated action
“It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.”
Stated action
“SECAmb does not specify a field of experience such as A&E or urgent care because the range of medical conditions and situations with which we deal on a daily basis is so wide. Experience in a wide range of disciplines in our clinical workforce in the 111 service is an advantage; a broad spectrum of experience in different clinical settings (e.g. cardiac, stroke, paediatrics, mental health) helps us to accommodate the extremely diverse needs of our patients.”
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 NHS England 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 |
|---|---|---|---|---|
| 2021 → 2024 | 0.71 | 0.23 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.