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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Organisation type
Theme
Relation
Reports
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Minimum confidence
At least
337 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Delayed mental health bed allocation leading to patient deterioration
Care Quality Commission · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Chest drain insertion without pre-procedure checks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Foreign conviction information not shared on arrest
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of antenatal screening for group B streptococcus
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Missed or delayed diagnosis of severe brain injury
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Repeated catheterisation without oversight or documentation
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of dedicated substance misuse team in police custody
National Police Chiefs' Council · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Unavailability of isoprenaline for heart transplant resuscitation
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of interpreter framework in healthcare settings
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Inappropriate use of intrapartum CTG guidance for antenatal monitoring
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Communication breakdown between junior doctor and consultant
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high