Unavailability of isoprenaline for heart transplant resuscitation
Department of Health and Social Care received 2 coroners' reports about this hazard between 14 Apr 2014 and 13 Oct 2014.
They came from 2 different coroners in 2 coroner areas. 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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Isoprenaline is not available in the United Kingdom and the source of the supply and the importance of the use of Isoprenaline in the resuscitation of heart transplanted patients should be brought to the attention of all hospitals and health professionals in the United Kingdom.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 3 specific actions.Response (PDF) ↗
“the Trust is now developing such guidelines (available 14" May)”
Stated timescale: 14 May
“England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
Stated timescale: immediately
1 more stated action in the Promises tab.
- 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“The Department of Health therefore asked the NHS UK Medicines Information service (UKMI) to produce a”
Stated timescale: 24 April 2014
- 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.
2014 → 2014Mary Fenton6 months after Paul Ashton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the unavailability or severe shortage of Isoprenaline needed for resuscitating heart‑transplant patients. They differ in focus: the earlier report stresses the lack of national availability and need for awareness, while the later report points to hospital‑level shortages and questions production responsibility.
Paul Ashton · 14 Apr 2014
“Isoprenaline is not available in the United Kingdom and the source of the supply and the importance of the use of Isoprenaline in the resuscitation of heart transplanted patients should be brought to the attention of all hospitals and health professionals in the United Kingdom.”
Original on judiciary.uk ↗ Mary Fenton · 13 Oct 2014
“This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally.”
Original on judiciary.uk ↗
Stated action · timescale: 14 May
“the Trust is now developing such guidelines (available 14" May)”
Stated action · timescale: immediately
“England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
Stated action · timescale: immediately
“NHS England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
Stated action · timescale: 24 April 2014
“The Department of Health therefore asked the NHS UK Medicines Information service (UKMI) to produce a”
- 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 |
|---|---|---|---|---|
| 2014 → 2014 | 0.79 | 0.24 | 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.