Inadequate escalation of clinical care
Gloucestershire Hospitals NHS Trust received 2 coroners' reports about this hazard between 21 Oct 2015 and 6 Apr 2017.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
No published response from Gloucestershire Hospitals NHS Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The clinical care provided to [name redacted] in the obstetric department was not escalated appropriately to more senior colleagues,”
Original on judiciary.uk ↗ No published response from Gloucestershire Hospitals NHS Trust was found for this report.
- 1 year 6 months laterClosely relatedConfidence 0.90 · high
“Whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to Gloucestershire Hospitals NHS 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.
2015 → 2017Steven Amos1 year 6 months after Samantha Beach · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern failures to escalate care when a patient's condition worsens.
Samantha Beach · 21 Oct 2015
“The clinical care provided to [name redacted] in the obstetric department was not escalated appropriately to more senior colleagues,”
Original on judiciary.uk ↗ Steven Amos · 6 Apr 2017
“Whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period.”
Original on judiciary.uk ↗
No published response from Gloucestershire Hospitals NHS Trust was found for this report.
No published response from Gloucestershire Hospitals NHS Trust was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Gloucestershire Hospitals NHS 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 |
|---|---|---|---|---|
| 2015 → 2017 | 0.80 | 0.04 | Closely related · 0.90 | same |
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.