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 Closely related Confidence 0.90+Clear all

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

Missed opportunity for appropriate VTE risk management
Worcestershire Acute Hospitals NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Communication failures and information sharing problems across trust
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed referral for neurosurgical care
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Staff unaware of leave policy requirements
Sussex Partnership NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Ambulance crew waiting in corridor due to insufficient clinical space
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed resuscitation due to insufficient staff awareness or training
Oxleas NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of sepsis detection tool in emergency call handling
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Misplaced nasogastric tube in patients with prior gastric surgery
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate shift handover communication leading to missed critical patient details
National Institute for Health and Care Excellence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed discharge increases infection risk for frail elderly patients
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate foreign body management guidance
Nottinghamshire Healthcare NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Role confusion due to title and lack of uniform
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Missing prescription and fluid balance documentation
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
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
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

All chains