Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-cool
UK Health Security Agency received 2 coroners' reports about this hazard between 31 Mar 2021 and 29 Jun 2023.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate”
Original on judiciary.uk ↗ UK Health Security Agency responded, stating 1 specific action.Response (PDF) ↗
“PHE will further update the risk estimates and ensure that these are published by September 2021”
Stated timescale: September 2021
- 2 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“There is an inconsistency between - Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection”
Original on judiciary.uk ↗ Repeated from the earlier report:riskMycobacteriumChimaera
The most recent report. A response may not be due or published yet.
- All reports to UK Health Security Agency
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 → 2023Clinton Fear2 years 3 months after Nicholas Winterton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern the accuracy and timeliness of information provided to patients about the risk of Mycobacterium Chimaera infection from heater‑cooler units. They differ in focus: the earlier report stresses the need for up‑to‑date risk estimates, while the later report highlights a mismatch between the January 2013 notification start date and evidence of earlier infections.
Nicholas Winterton · 31 Mar 2021
“It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate”
Original on judiciary.uk ↗ Clinton Fear · 29 Jun 2023
“There is an inconsistency between - Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“PHE will further update the risk estimates and ensure that these are published by September 2021”
Stated action · timescale: September 2021
“PHE will further update the risk estimates and ensure that these are published by September 2021”
No published response from UK Health Security Agency 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 UK Health Security Agency 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 → 2023 | 0.82 | 0.33 | 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.