Omission of long‑acting insulin dose during inpatient care
Stockport NHS Foundation Trust received 2 coroners' reports about this hazard between 23 Mar 2015 and 20 Jan 2016.
They came from 1 coroner. 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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'”
Original on judiciary.uk ↗ Stockport NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust has also implemented an electronic inpatient referral form for patients needing review, which provides a more robust method for all ward areas to request help or support in managing patients with diabetes.”
- 10 months laterIdentical hazardConfidence 0.95 · high
“During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin”
Original on judiciary.uk ↗ Stockport NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“Trust is moving towards a Trust wide electronic patient record (EPR) which should resolve this issue, but in the meantime, | can confirm that there isa specialist "Task& Finish Group" in-place to further review this issue and develop.an effective interim solution. This group reports to the Trust's Risk Management Committee and through this to the Quality Governance Committee and the Quality Assurance Committee, which reports directly to the Board”
- All reports to Stockport 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.
2015 → 2016Steven Rogers10 months after Pamela Pattison · same coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight the omission of a prescribed long‑acting insulin dose during inpatient care.
Pamela Pattison · 23 Mar 2015
“ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'”
Original on judiciary.uk ↗ Steven Rogers · 20 Jan 2016
“During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin”
Original on judiciary.uk ↗
Stated action
“The Trust has also implemented an electronic inpatient referral form for patients needing review, which provides a more robust method for all ward areas to request help or support in managing patients with diabetes.”
Stated action
“Trust is moving towards a Trust wide electronic patient record (EPR) which should resolve this issue, but in the meantime, | can confirm that there isa specialist "Task& Finish Group" in-place to further review this issue and develop.an effective interim solution. This group reports to the Trust's Risk Management Committee and through this to the Quality Governance Committee and the Quality Assurance Committee, which reports directly to the Board”
- 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 Stockport 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 |
|---|---|---|---|---|
| 2015 → 2016 | 0.79 | 0.50 | Identical · 0.95 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Stockport NHS Foundation Trust
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.