Delayed trans-oesophageal echocardiogram availability and staffing
Greater Manchester Integrated Care received 2 coroners' reports about this hazard between 19 Jul 2023 and 2 Jul 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”
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
- 11 months laterClosely relatedConfidence 0.85 · high
“significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals”
Original on judiciary.uk ↗ Greater Manchester Integrated Care responded.Response (PDF) ↗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 → 2024James Cockburn11 months after Michael Amesbury · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight delays in obtaining trans‑oesophageal echocardiograms that hinder timely cardiac assessment and treatment planning. The earlier report stresses poor information sharing and referral processes, while the later report adds a shortage of qualified staff and ongoing communication barriers.
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”
Original on judiciary.uk ↗ James Cockburn · 2 Jul 2024
“significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals”
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.
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 | 0.71 | 0.34 | Closely related · 0.85 | 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.