Delayed referral for neurosurgical care
NHS England received 2 coroners' reports about this hazard between 18 Jan 2017 and 17 Jun 2026.
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.
“absence of a clear pathway for referral for life-saving neurosurgery”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The Neurosciences CRG are in the process of reviewing the Neurosurgery Service Specification and will require all services to meet the guidelines issued by the SBNS. This review will be complete by'31 March 2018.”
Stated timescale: 31 March 2018
- 9 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“neurosurgery is not a specified Pathways category, nor is it part of the”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- All reports to NHS England
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.
2017 → 2026Muluembet Yohanes9 years 5 months after Teresa Dennett · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the lack of a defined pathway or algorithm for referring patients needing neurosurgical care. The earlier report concerns hospital referral pathways, while the later report concerns the NHS 111 triage algorithm.
Teresa Dennett · 18 Jan 2017
“absence of a clear pathway for referral for life-saving neurosurgery”
Original on judiciary.uk ↗ Muluembet Yohanes · 17 Jun 2026
“neurosurgery is not a specified Pathways category, nor is it part of the”
Original on judiciary.uk ↗
Stated action · timescale: 31 March 2018
“The Neurosciences CRG are in the process of reviewing the Neurosurgery Service Specification and will require all services to meet the guidelines issued by the SBNS. This review will be complete by'31 March 2018.”
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 NHS England 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 |
|---|---|---|---|---|
| 2017 → 2026 | 0.77 | 0.15 | 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.