Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED
Barts Health NHS Trust received 3 coroners' reports about this hazard between 27 Aug 2024 and 16 Jun 2025.
They came from 2 different coroners. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia”
- 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded.Response (PDF) ↗
- 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors.”
Original on judiciary.uk ↗ Repeated from the earlier report:departmentNEWSclinical
Barts Health NHS Trust responded.Response (PDF) ↗
- All reports to Barts Health 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.
2024 → 2025Abdirahman Afrah9 months after Dave Onawelo · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in emergency department processes that delay identification of deteriorating patients. The earlier report cites congestion and over-reliance on NEWS; the later report cites lack of timely triage and excessive waiting times.
Dave Onawelo · 27 Aug 2024
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
Original on judiciary.uk ↗ Abdirahman Afrah · 27 May 2025
“There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage.”
Original on judiciary.uk ↗ 2024 → 2025Norma Campbell10 months after Dave Onawelo · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in the emergency department related to the use of NEWS scores and inadequate monitoring of deteriorating patients.
Dave Onawelo · 27 Aug 2024
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
Original on judiciary.uk ↗ Norma Campbell · 16 Jun 2025
“There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia”
Stated action
“the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia”
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 Barts Health 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.71 | 0.02 | Closely related · 0.80 | different |
| 2024 → 2025 | 0.70 | 0.07 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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- Governance failure in incident identification and poor quality of clinical notes3 reports · 2023–2025
- Lack of strategic governance hindering incident identification2 reports · 2023–2025
- Absence of falls care plan3 reports · 2015–2024
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.