Missing radiology discussion records for children
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust received 2 coroners' reports about this hazard between 28 Jul 2021 and 25 Feb 2025.
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.
“No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)”
Original on judiciary.uk ↗ Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“A sepsis audit tool Task and Finish group with MDT input from both Paediatric and ED teams has been set up to review the audit tool for sepsis management, which will audit the pathway from the point of arrival in the Emergency Department. Due to the complexity of the different referral pathways this is a complex audit tool to develop, it is currently in the final stages of development, the aim is to pilot this in Q3. For Q2 the current audit tool will be used.”
Stated timescale: Q3 pilot
- 3 years 7 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team.”
Original on judiciary.uk ↗ Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Doncaster and Bassetlaw Teaching Hospitals 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.
2021 → 2025Khadija Kerri3 years 7 months after Jacob Owczarek · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth concerns involve shortcomings in how radiology-related information is communicated or recorded within the trust. The earlier issue was about missing records of paediatric case discussions in radiology meetings, while the later issue is about lacking a policy to share external radiology addendum reports with clinical teams.
Jacob Owczarek · 28 Jul 2021
“No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)”
Original on judiciary.uk ↗ Khadija Kerri · 25 Feb 2025
“There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team.”
Original on judiciary.uk ↗
Stated action · timescale: Q3 pilot
“A sepsis audit tool Task and Finish group with MDT input from both Paediatric and ED teams has been set up to review the audit tool for sepsis management, which will audit the pathway from the point of arrival in the Emergency Department. Due to the complexity of the different referral pathways this is a complex audit tool to develop, it is currently in the final stages of development, the aim is to pilot this in Q3. For Q2 the current audit tool will be used.”
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 Doncaster and Bassetlaw Teaching Hospitals 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 |
|---|---|---|---|---|
| 2021 → 2025 | 0.69 | 0.06 | Closely related · 0.80 | 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.