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
656 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Inaccurate early warning score calculation by clinical staff
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Missing escort records during reception screening
His Majesty's Prison and Probation Service · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate patient information handover between care settings
Manchester Clinical Commissioning Group · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Delayed ambulance arrival due to resource shortages
Welsh Ambulance Trust · Ambulance service
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate staff training and understanding of ACCT protocol
HMP Pentonville · Prison or detention
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Excessive speed limit on bridge and junction
National Highways · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Inconsistent antenatal CTG interpretation leading to delayed response
Royal College of Obstetricians and Gynaecologists · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inadequate dissemination of protocol changes to frontline staff
East Midlands Ambulance Service NHS Trust · Ambulance service
2 reports · 1 coronerIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Inconsistent discharge policy application
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Absence of structured care plans for high-risk patients
Central and North West London NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.92 · highNo published response to an earlier report
- Inadequate nighttime patient observation documentation
The Priory Group · Company or provider
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high