Missed breech presentation due to lack of routine prenatal scanning
Department of Health and Social Care received 2 coroners' reports about this hazard between 19 Dec 2013 and 25 Jul 2018.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- 4 years 7 months laterIdentical hazardConfidence 0.92 · higha different coroner
“pre delivery scans are not routinely carried out to try and reduce the number of undetected breeches and midwives/doctors rely on external examination.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2013 → 2018Aniyah Winston4 years 7 months after Leo Deady · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight the problem of undiagnosed breech presentations due to the absence of routine prenatal scanning.
Leo Deady · 19 Dec 2013
“there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed.”
Original on judiciary.uk ↗ Aniyah Winston · 25 Jul 2018
“pre delivery scans are not routinely carried out to try and reduce the number of undetected breeches and midwives/doctors rely on external examination.”
Original on judiciary.uk ↗
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2013 → 2018 | 0.75 | 0.18 | Identical · 0.92 | 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.