Delayed referral to vascular services
Greater Manchester Integrated Care received 2 coroners' reports about this hazard between 19 Jul 2023 and 13 Mar 2024.
They came from 1 coroner. 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.
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;”
Original on judiciary.uk ↗ Greater Manchester Integrated Care responded, stating 1 specific action.Response (PDF) ↗
“We are looking at how we can bring the benefits of this type of technology to other services.”
Stated timescale: October 2023
- 8 months laterClosely relatedConfidence 0.86 · high
“The evidence before the inquest was that there were multiple specialisms across multiple GM Trusts with different IT systems involved in Mr [name redacted] care. As a consequence communication was poor with a limited understanding of his overall condition and fragmented input.”
Original on judiciary.uk ↗ Repeated from the earlier report:differentsystems
Greater Manchester Integrated Care responded.Response (PDF) ↗
- All reports to Greater Manchester Integrated 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 → 2024Alan Smith8 months after Michael Amesbury · same coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight problems with delayed or ineffective referrals due to fragmented systems and poor communication across trusts.
Michael Amesbury · 19 Jul 2023
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;”
Original on judiciary.uk ↗ Alan Smith · 13 Mar 2024
“The evidence before the inquest was that there were multiple specialisms across multiple GM Trusts with different IT systems involved in Mr [name redacted] care. As a consequence communication was poor with a limited understanding of his overall condition and fragmented input.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are looking at how we can bring the benefits of this type of technology to other services.”
Stated action · timescale: October 2023
“We are looking at how we can bring the benefits of this type of technology to other services.”
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 Greater Manchester Integrated 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 | 0.65 | 0.07 | Closely related · 0.86 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Greater Manchester Integrated Care
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.