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
349 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delayed resuscitation due to insufficient staff awareness or training
Oxleas NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of CPR training among carers
Health and Safety Executive · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate weekend mental health provision at prison
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Adhesions leading to small bowel obstruction
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coronersClosely relatedConfidence 0.90 · high - Insufficient patient observation leading to inpatient falls
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Insufficient awareness of immersion pulmonary oedema risk for high bloodpressure
British Diving Safety Group · Company or provider
2 reports · 2 coronersIdentical hazardConfidence 0.92 · high - 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Unclear wording in NHS Pathways triage questions
NHS England · National body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 2 coronersIdentical hazardConfidence 0.92 · high
- Inadequate ACCT case management at HMP Woodhill
HMP Woodhill · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Absence of in-cell automatic fire detection
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Gap in classification and remit leading to insufficient investigation
Metropolitan Police Service · Police
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.93 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report