Missed or delayed diagnosis of severe brain injury
National Institute for Health and Care Excellence received 2 coroners' reports about this hazard between 17 Feb 2014 and 15 Jul 2015.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from National Institute for Health and Care Excellence was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The Emergency Department doctors indicated that they could not get a CT of the head because "the NICE Guidelines do not indicate as being appropriate where there are no obvious neurological signs".”
Original on judiciary.uk ↗ No published response from National Institute for Health and Care Excellence was found for this report.
- 1 year 5 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to National Institute for Health and Care Excellence
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 → 2015Karen O'Brien1 year 5 months after Selina Broadhurst · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that clinicians are applying NICE guidance too rigidly, leading to inadequate patient assessment. The earlier case concerns missed head injury due to lack of neurological signs; the later case concerns overriding a GP request without proper evaluation.
Selina Broadhurst · 17 Feb 2014
“The Emergency Department doctors indicated that they could not get a CT of the head because "the NICE Guidelines do not indicate as being appropriate where there are no obvious neurological signs".”
Original on judiciary.uk ↗ Karen O'Brien · 15 Jul 2015
“The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment.”
Original on judiciary.uk ↗
No published response from National Institute for Health and Care Excellence was found for this report.
No published response from National Institute for Health and Care Excellence was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 National Institute for Health and Care Excellence 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 | 0.66 | 0.08 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for National Institute for Health and Care Excellence
- Inadequate shift handover communication leading to missed critical patient details2 reports · 2019–2026
- Inconsistent interpretation of antenatal CTG leading to delayed response2 reports · 2014–2025
- Insufficient anticoagulation guidance for immobilised patients2 reports · 2023–2024
- Continuing medication for VTE risk after discharge2 reports · 2019–2023
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.