Forgotten biliary stent without registry
Department of Health and Social Care received 2 coroners' reports about this hazard between 28 Jun 2018 and 18 Jul 2022.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- 4 years 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients.”
Original on judiciary.uk ↗ Repeated from the earlier report:registrystents
Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Care Quality Commission (CQC) inspected the Barking, Havering and Redbridge University Trust in November 2021 where the Urgent Care and Emergency Services (UEC) at the Queen's Hospital were inspected. Concerns were identified and the Trust worked with local system partners to create an action plan to address these. CQC intends to inspect the UEC at the Queen's Hospital again and will consider the Trust's response to the Coroner in these inspection plans. In the meantime, CQC will monitor the”
“We agree that ensuring patients and their GP are aware of the potential symptoms from stents, including symptoms mimicking urinary tract infection (UTI), as well as confirmed symptomatic microbiologically confirmed UTI that could be caused by a stent.”
- 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.
2018 → 2022Graham White4 years 1 month after Stephen Whitehead · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the lack of a registry or safety‑netting system to track patients with stents and enable monitoring or recall. The earlier report calls for a national biliary stent registry, while the later report notes the trust had no stent registry for monitoring and recall.
Stephen Whitehead · 28 Jun 2018
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
Original on judiciary.uk ↗ Graham White · 18 Jul 2022
“Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action
“The Care Quality Commission (CQC) inspected the Barking, Havering and Redbridge University Trust in November 2021 where the Urgent Care and Emergency Services (UEC) at the Queen's Hospital were inspected. Concerns were identified and the Trust worked with local system partners to create an action plan to address these. CQC intends to inspect the UEC at the Queen's Hospital again and will consider the Trust's response to the Coroner in these inspection plans. In the meantime, CQC will monitor the”
Stated action
“We agree that ensuring patients and their GP are aware of the potential symptoms from stents, including symptoms mimicking urinary tract infection (UTI), as well as confirmed symptomatic microbiologically confirmed UTI that could be caused by a stent.”
- 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 |
|---|---|---|---|---|
| 2018 → 2022 | 0.68 | 0.30 | 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.