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
75 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 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of transport suitability assessment for changing patient conditions
Barts Health NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Disjointed clinical information system leading to data loss risk
Tameside and Glossop Integrated Care NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Communication failures and information sharing problems across trust
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.95 · high
- Untrained staff conducting mental health assessments
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.92 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 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
- Insufficient patient observation leading to inpatient falls
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical 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
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Fragmented communication between mental and physical health services
Southern Health NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Governance failure in incident identification and poor quality of clinical notes
Barts Health NHS Trust · NHS body
3 reports · 1 coronerIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report