Inadequate audit of 111 call errors
NHS England received 2 coroners' reports about this hazard between 19 Dec 2014 and 27 Jan 2020.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from NHS England was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 5 years 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“Following Ms [name redacted] death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients' weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included”
Stated timescale: October 2019
“we will consider how best to make clear In CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at 811 tfflls.”
- 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.
2014 → 2020Shanté Turay-Thomas5 years 1 month after Samia Shara · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight shortcomings in the audit process of emergency calls that hinder learning and improvement.
Samia Shara · 19 Dec 2014
“That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities”
Original on judiciary.uk ↗ Shanté Turay-Thomas · 27 Jan 2020
“When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways.”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
Stated action · timescale: October 2019
“Following Ms [name redacted] death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients' weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included”
Stated action
“we will consider how best to make clear In CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at 811 tfflls.”
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 |
|---|---|---|---|---|
| 2014 → 2020 | 0.77 | 0.12 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
- Delayed referral for neurosurgical care2 reports · 2017–2026
- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
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.