Lack of integrated multidisciplinary care across sites
University Hospitals Birmingham NHS Foundation Trust received 2 coroners' reports about this hazard between 22 Jan 2019 and 30 Jun 2023.
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.
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols.”
Original on judiciary.uk ↗ University Hospitals Birmingham NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019.”
Stated timescale: June 2019
- 4 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding.”
Original on judiciary.uk ↗ University Hospitals Birmingham NHS Foundation Trust responded.Response (PDF) ↗
- All reports to University Hospitals Birmingham 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.
2019 → 2023Sinon Masha4 years 5 months after Ann Swoffer · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of integrated, consistent multidisciplinary care across the Trust’s sites, leading to fragmented processes and communication risks.
Ann Swoffer · 22 Jan 2019
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols.”
Original on judiciary.uk ↗ Sinon Masha · 30 Jun 2023
“Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019.”
Stated action · timescale: June 2019
“The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019.”
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 University Hospitals Birmingham 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 |
|---|---|---|---|---|
| 2019 → 2023 | 0.66 | 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.