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recurance

Anne Dyson

26 Aug 2025 · Coroner David Place · Sunderland

The coroner's concerns

  1. 1. inconsistent scan interpretation leading to missed malignancy

    “The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken. I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report. The evidence indicated that Radiologists are not provided with a list or a summary of a patient's symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period. I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed.”

Responses

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  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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