Skip to content
recurance

Mark Villers

3 Jun 2025 · Coroner Louise Hunt · Birmingham and Solihull

The coroner's concerns

  1. 1. insufficient radiologists to report weekend CT scans

    “1. The investigation by the hospital trust identified that at the time of Mr [name redacted]' presentation to hospital on 18/05/24 there were insufficient radiologists to report the large number of CT scans undertaken over the weekend period. This was one of the root causes of the very subtle abnormality indicating aortic dissection being missed when the scan was reported. The inquest heard evidence that whilst the situation had improved the number of radiologists was still not in accordance with Royal”

Responses

  • Built with
  • 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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error