Missed CT scan authorisation and delayed staging scans
ABMU Health Board received 2 coroners' reports about this hazard between 12 Nov 2019 and 28 Jul 2025.
They came from 1 coroner in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from ABMU Health Board was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.”
Original on judiciary.uk ↗ No published response from ABMU Health Board was found for this report.
- 5 years 8 months laterClosely relatedConfidence 0.80 · moderate
“Two Associate Medical Directors have communicated that delays in undertaking staging scans are ongoing and are having an impact on survivability rates and prognoses by making treatable cancers irresectable.”
Original on judiciary.uk ↗ ABMU Health Board responded.Response (PDF) ↗
- All reports to ABMU Health Board
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.
2019 → 2025Gareth Tatchell5 years 8 months after Pamela Moran · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight delays in obtaining necessary imaging scans that can affect patient outcomes. The earlier report focuses on missed overnight CT scan authorisation, while the later report concerns ongoing delays in staging scans for cancer diagnosis.
Pamela Moran · 12 Nov 2019
“There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.”
Original on judiciary.uk ↗ Gareth Tatchell · 28 Jul 2025
“Two Associate Medical Directors have communicated that delays in undertaking staging scans are ongoing and are having an impact on survivability rates and prognoses by making treatable cancers irresectable.”
Original on judiciary.uk ↗
No published response from ABMU Health Board was found for this report.
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 ABMU Health Board 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 |
|---|---|---|---|---|
| 2019 → 2025 | 0.63 | 0.01 | Closely related · 0.80 | same |
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.