Delayed urgent referrals and escalations
Cumbria Health Limited received 2 coroners' reports about this hazard between 8 Jul 2024 and 30 Jun 2025.
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.
“Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly”
Original on judiciary.uk ↗ Cumbria Health Limited responded, stating 1 specific action.Response (PDF) ↗
“We will put on educational sessions to update our clinicians on the mental capacity act, managing challenging scenarios with particular emphasis on how this is documented in a patient record”
- 1 year laterClosely relatedConfidence 0.85 · high
“[the deceased]'s case was sent electronically to the service, marked for 2 hour attention”
Original on judiciary.uk ↗ Cumbria Health Limited responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Cumbria Health Limited
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.
2024 → 2025Thomas Mallinson1 year after Michael Huggon · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that urgent requests or referrals are not being handled promptly, leading to avoidable harm. The earlier report focuses on delayed handover and after‑hours coverage, while the later report concerns an electronically flagged 2‑hour referral that was not acted on due to workload.
Michael Huggon · 8 Jul 2024
“Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly”
Original on judiciary.uk ↗ Thomas Mallinson · 30 Jun 2025
“[the deceased]'s case was sent electronically to the service, marked for 2 hour attention”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will put on educational sessions to update our clinicians on the mental capacity act, managing challenging scenarios with particular emphasis on how this is documented in a patient record”
Stated action
“We will put on educational sessions to update our clinicians on the mental capacity act, managing challenging scenarios with particular emphasis on how this is documented in a patient record”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Cumbria Health Limited 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 |
|---|---|---|---|---|
| 2024 → 2025 | 0.68 | 0.04 | Closely related · 0.85 | 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.