Repeated catheterisation without oversight or documentation
Department of Health and Social Care received 2 coroners' reports about this hazard between 29 Apr 2014 and 15 May 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 Department of Health and Social Care was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The deceased was catheterised too frequently without the management of a urologist.”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 1 year 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record.”
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.
2014 → 2015George Richardson1 year 1 month after Stephen Widman · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with repeated or multiple catheterisation procedures performed without proper oversight or documentation. The earlier report stresses excessive frequency without urologist involvement, while the later report notes lack of a consolidated record leading to uncoordinated attempts.
Stephen Widman · 29 Apr 2014
“The deceased was catheterised too frequently without the management of a urologist.”
Original on judiciary.uk ↗ George Richardson · 15 May 2015
“Catheterisation was carried out including attempts/manipulation on several occasions by different individuals without recourse to a consolidated catheterisation record.”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
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 |
|---|---|---|---|---|
| 2014 → 2015 | 0.76 | 0.20 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
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.