Lack of serious incident review and mandatory root cause analysis training
University Hospital of North Midlands received 2 coroners' reports about this hazard between 7 Apr 2016 and 19 Apr 2021.
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 University Hospital of North Midlands was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
Original on judiciary.uk ↗ No published response from University Hospital of North Midlands was found for this report.
- 5 years later
Raised again · 1st time
Stephen Oakes↗
19 Apr 2021 · Margaret Jones · Stoke-on-Trent & North Staffordshire Coroner's Court
Closely relatedConfidence 0.90 · higha different coroner“(5) There is no compulsory training of clinicians required to undertake root cause analysis.”
Original on judiciary.uk ↗ Repeated from the earlier report:rootcauseanalysis
University Hospital of North Midlands responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to University Hospital of North Midlands
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.
2016 → 2021Stephen Oakes5 years after Nadim Butt · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight deficiencies in the hospital's approach to root cause analysis, either by not elevating issues to RCA or by lacking compulsory training for clinicians to conduct RCA.
Nadim Butt · 7 Apr 2016
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
Original on judiciary.uk ↗ Stephen Oakes · 19 Apr 2021
“(5) There is no compulsory training of clinicians required to undertake root cause analysis.”
Original on judiciary.uk ↗
No published response from University Hospital of North Midlands was found for this report.
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.
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 University Hospital of North Midlands 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 |
|---|---|---|---|---|
| 2016 → 2021 | 0.76 | 0.32 | 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.