Delay in reporting original x-ray findings to clinicians
Department of Health and Social Care received 2 coroners' reports about this hazard between 22 Sept 2015 and 16 Oct 2023.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“(1) There was a delay of 5 days in the formal reporting of the original X-ray;”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“HEE will work with key partners, including the RCR, to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests.”
- 8 years 1 month laterIdentical hazardConfidence 0.90 · higha different coroner
“A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗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.
2015 → 2023Claire Twinn8 years 1 month after William Harnell · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a significant delay in the reporting of radiological imaging results. The core issue is the untimely communication of X-ray findings to clinicians.
William Harnell · 22 Sept 2015
“(1) There was a delay of 5 days in the formal reporting of the original X-ray;”
Original on judiciary.uk ↗ Claire Twinn · 16 Oct 2023
“A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023.”
Original on judiciary.uk ↗
Stated action
“HEE will work with key partners, including the RCR, to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests.”
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 |
|---|---|---|---|---|
| 2015 → 2023 | 0.86 | 0.17 | 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.