Inaccurate early warning score calculation by clinical staff
Department of Health and Social Care received 2 coroners' reports about this hazard between 24 Sept 2013 and 19 Jul 2017.
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 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗
“work is already being taken forward. In July 2012 a report entitled National early warning score (NEWS); standardising the assessment of acute-illness severity in the NHS, was published by the Royal College of Physicians.”
Stated timescale: July 2012
“The system operational in a Birmingham Trust depends on patient observations being recorded in the Patient Information Communication System (PICS), the Trust's rules-based clinical information, drug prescribing and administration system. As observations are entered an early warning score is generated. Depending on the score generated and the settings programmed, an automatic message can be sent to designated nursing and medical staff.”
- 3 years 10 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“there - were problems with the Registered Nurses' ability to calculate early warning scores accurately”
Original on judiciary.uk ↗ Repeated from the earlier report:earlywarning
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the Trust has agreed that all patients will be reviewed daily by the medical team and that the Trust is currently looking to ensure that all trauma patients with severe systemic illness will be reviewed daily by a medical doctor. This will be monitored through Trust audits.”
- 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.
2013 → 2017Edith Robinson3 years 10 months after Jude Augustus Gordon · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with the accurate calculation of Early Warning Scores by clinical staff. They differ in focus: the earlier report cites inconsistent methods across trusts and lack of a national system, while the later report stresses nurses' calculation inaccuracies as a national issue.
Jude Augustus Gordon · 24 Sept 2013
“It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual.”
Original on judiciary.uk ↗ Edith Robinson · 19 Jul 2017
“there - were problems with the Registered Nurses' ability to calculate early warning scores accurately”
Original on judiciary.uk ↗
Stated action · timescale: July 2012
“work is already being taken forward. In July 2012 a report entitled National early warning score (NEWS); standardising the assessment of acute-illness severity in the NHS, was published by the Royal College of Physicians.”
Stated action
“The system operational in a Birmingham Trust depends on patient observations being recorded in the Patient Information Communication System (PICS), the Trust's rules-based clinical information, drug prescribing and administration system. As observations are entered an early warning score is generated. Depending on the score generated and the settings programmed, an automatic message can be sent to designated nursing and medical staff.”
Stated action
“the Trust has agreed that all patients will be reviewed daily by the medical team and that the Trust is currently looking to ensure that all trauma patients with severe systemic illness will be reviewed daily by a medical doctor. This will be monitored through Trust audits.”
- 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 |
|---|---|---|---|---|
| 2013 → 2017 | 0.80 | 0.27 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social 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.