Adhesions leading to small bowel obstruction
NHS England received 2 coroners' reports about this hazard between 30 Sept 2024 and 10 May 2026.
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.
“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 1 year 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There are other clinics nationally who may be offering patients Preoperative Progressive Pneumoperitoneum (PPP) to patients who have a history of adhesional small bowel obstruction (ASBO).”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- All reports to NHS England
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.
2024 → 2026Glen Jay1 year 7 months after Megan Williams · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports concern abdominal adhesions leading to small bowel obstruction. The earlier case involved spontaneous band adhesions causing obstruction, while the later case warns that a procedure can exacerbate adhesions and cause obstruction.
Megan Williams · 30 Sept 2024
“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.”
Original on judiciary.uk ↗ Glen Jay · 10 May 2026
“There are other clinics nationally who may be offering patients Preoperative Progressive Pneumoperitoneum (PPP) to patients who have a history of adhesional small bowel obstruction (ASBO).”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.”
No specific action could be extracted with a verified quote.
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 NHS England 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 |
|---|---|---|---|---|
| 2024 → 2026 | 0.57 | 0.32 | Identical · 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.