Communication breakdown between junior doctor and consultant
Department of Health and Social Care received 2 coroners' reports about this hazard between 14 Oct 2013 and 29 Aug 2014.
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 Department of Health and Social Care was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Breakdown in communication between the junior doctor and consultant. - The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 10 months laterClosely relatedConfidence 0.90 · higha different coroner
“There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation”
Original on judiciary.uk ↗ Repeated from the earlier report:breakdowncommunication
Department of Health and Social Care responded.Response (PDF) ↗
- 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 → 2014Jude Kliem10 months after Frederick Davidson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify a breakdown in communication as a safety concern. The earlier report ties it to junior‑doctor/consultant interaction, while the later report calls for standardized documentation to improve communication.
Frederick Davidson · 14 Oct 2013
“Breakdown in communication between the junior doctor and consultant. - The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment”
Original on judiciary.uk ↗ Jude Kliem · 29 Aug 2014
“There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care 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 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 → 2014 | 0.75 | 0.28 | Closely related · 0.90 | different |
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.