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
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At least
29 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delayed referral for neurosurgical care
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Ambulance crew waiting in corridor due to insufficient clinical space
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 1 coronerIdentical hazardConfidence 0.95 · high
- 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 - 2 reports · 2 coronersClosely 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 coronersClosely relatedConfidence 0.90 · high - Delayed discharge increases infection risk for frail elderly patients
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 1 coronerIdentical hazardConfidence 0.96 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Patients not informed of surgical risks in Turkey
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 coronersClosely 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 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Recurring hazard (see the quoted concerns)
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical 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 coronerIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high