Lack of communication between specialties
Department of Health and Social Care received 2 coroners' reports about this hazard between 15 Nov 2023 and 20 Dec 2024.
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.
“That one of the teams caring for Mr [name redacted] was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr [name redacted] care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.”
Original on judiciary.uk ↗ Repeated from the earlier report:referralteamspecialty
Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2023 → 2024Antony Williamson1 year 1 month after Calogero Di Blasi · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify a failure of communication between different specialty teams that prevents timely sharing of important clinical information. They differ in that the earlier case concerns unawareness of a specific CT scan affecting an endoscopy decision, while the later case describes a general absence of liaison across specialties in complex care.
Calogero Di Blasi · 15 Nov 2023
“That one of the teams caring for Mr [name redacted] was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway.”
Original on judiciary.uk ↗ Antony Williamson · 20 Dec 2024
“Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr [name redacted] care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.”
Original on judiciary.uk ↗
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.77 | 0.16 | 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.