Repeated warnings

Each one is a single concern, raised with the same organisation in two or more coroners' reports at least six months apart. Nemotron Super judged every match to be the same or a closely related hazard, and both quotes are checked word for word against the reports.

Organisation type

Ambulance service25 Commissioner6 Company or provider10 Local authority28 National body342 NHS body Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health72 Products and workplaces9 Roads and rail53 Suicide197 Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:NHS body 3+ reports Confidence 0.80+Clear all

39 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Inadequate risk assessment documentation and inaccurate record keeping
Essex Partnership University NHS Foundation Trust · NHS body
6 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate medical documentation in acute trust
Mid and South Essex NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Staff unaware of leave policy requirements
Sussex Partnership NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate ACCT documentation and communication
Central and North West London NHS Foundation Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.80 · moderate
Governance failure in incident identification and poor quality of clinical notes
Barts Health NHS Trust · NHS body
3 reports · 1 coroner
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Inaccurate or falsified patient observations
East London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate record keeping leading to outdated patient information
Essex Partnership NHS Foundation Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Ambulance handover delays at emergency department
Aneurin Bevan University Health Board · NHS body
3 reports · 3 coroners
Identical hazardConfidence 0.90 · high
Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED
Barts Health NHS Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Incomplete risk assessment before discharge
North East London Foundation Trust · NHS body
4 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Risk of suicide in mental health care
Midlands Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · high
Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inability to access GP medication records across systems
Essex Partnership University NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Absence of falls care plan
Barts Health NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Physical health check delays mental health referrals
Norfolk and Suffolk NHS Foundation Trust · NHS body
5 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Medication monitoring and discharge risk assessment failures
Pennine Care NHS Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Incomplete risk assessment documentation and communication
Devon Partnership NHS Trust · NHS body
4 reports · 4 coroners
Closely relatedConfidence 0.80 · moderate

All chains