Lack of communication between specialties and roles
Manchester University NHS Foundation Trust received 2 coroners' reports about this hazard between 16 Jul 2018 and 19 Jun 2024.
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 Manchester University NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Communication between speciality consultants ~ lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks”
Original on judiciary.uk ↗ No published response from Manchester University NHS Foundation Trust was found for this report.
- 5 years 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“there does not appear to be clear guidance available to those working within the Trust as to what is required when communicating (particularly as to test results and a patient's presentation) as between different specialisms and as between different roles within the team.”
Original on judiciary.uk ↗ Manchester University NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“we have focused on the Human Factors of errors in clinical medicine and have engaged with our Human Factors Academy (HFA). This will support us to understand better the other factors at play which contribute to incorrect ECG interpretation; and which can be mitigated in the future. 1”
Stated timescale: 2024-08-08
- All reports to Manchester University 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.
2018 → 2024Thomas Gibson5 years 11 months after Sheila Ridgway · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient mechanisms for effective communication between different medical specialties within the trust. The earlier report notes a missing system for sharing risk information, while the later report points to absent clear guidance on communicating test results and patient presentations across specialisms and roles.
Sheila Ridgway · 16 Jul 2018
“Communication between speciality consultants ~ lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks”
Original on judiciary.uk ↗ Thomas Gibson · 19 Jun 2024
“there does not appear to be clear guidance available to those working within the Trust as to what is required when communicating (particularly as to test results and a patient's presentation) as between different specialisms and as between different roles within the team.”
Original on judiciary.uk ↗
No published response from Manchester University NHS Foundation Trust was found for this report.
Stated action · timescale: 2024-08-08
“we have focused on the Human Factors of errors in clinical medicine and have engaged with our Human Factors Academy (HFA). This will support us to understand better the other factors at play which contribute to incorrect ECG interpretation; and which can be mitigated in the future. 1”
- 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 Manchester University 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 |
|---|---|---|---|---|
| 2018 → 2024 | 0.73 | 0.07 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Manchester University 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.