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 body175 Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care 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:Hospital care Confidence 0.90+Clear all

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

Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · 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
Inadequate clinical documentation of patient condition and decisions
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate clinical records hinder investigations
Barking · Other
5 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Long waiting times for psychological assessment
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Misplaced or removed nasogastric tube
Barts Health NHS Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Delayed sepsis recognition and treatment
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Recurring hazard (see the quoted concerns)
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Inadequate clinical records hinder investigations
Department of Health and Social Care · National body
3 reports · 1 coroner
Identical hazardConfidence 0.90 · high
Lack of communication between specialties and roles
Manchester University NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Delayed escalation and inadequate fluid monitoring
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate documentation of clinical decisions
Barts Health NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Risk assessment tool overlooks DVT risk factors
Department of Health and Social Care · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Delayed neurology outpatient appointments increase SUDEP risk
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Misplaced central venous line
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Continuing medication for VTE risk after discharge
National Institute for Health and Care Excellence · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Undeclared allergens leading to anaphylaxis in food businesses
Food Standards Agency · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Fragmented transfer information across records
University Hospitals of Derby and Burton · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Forgotten biliary stent without registry
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report

All chains