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.
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Theme
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At least
533 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Critical clinical information lost during verbal handover
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of personal care and health deterioration in domiciliary care
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Delayed bespoke care placement arrangements
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Lack of communication between specialties and roles
Manchester University NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Incomplete paperwork and missing responsible clinician for section 5(2) holds
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of post discharge support for high risk patients
Leicestershire Partnership NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Inadequate resuscitation training clarity
HMP Wandsworth · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Insufficient probation officer staffing creates safety risks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Delay in obtaining timely imaging reports
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Delayed escalation and inadequate fluid monitoring
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high