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 3+ reports Clear all

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

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
Inadequate documentation of patient observations and assessments
Doncaster Royal Infirmary · Other
3 reports · 3 coroners
Closely relatedConfidence 0.86 · 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 records hinder investigations
Barking · Other
5 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine · National body
3 reports · 3 coroners
Closely relatedConfidence 0.86 · highNo published response to an earlier report
Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Unnecessary patient transfers without proper documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate record keeping and retention compromising care
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.82 · moderateNo published response to an earlier report
Lack of risk assessment documentation and updates
Pennine Acute Hospitals NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete handover documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
5 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate communication between clinical staff and families
Tameside Hospital NHS Foundation Trust · NHS body
4 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

All chains