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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At least
90 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Discharge without surgical review or sepsis recognition
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Missing prescription and fluid balance documentation
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of VTE assessment and missing anticoagulation documentation
Worcestershire Acute Hospitals NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 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 - Insufficient anticoagulation guidance for immobilised patients
National Institute for Health and Care Excellence · National body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 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 - 5 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Lack of communication between specialties and roles
Manchester University NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delay in obtaining timely imaging reports
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Delayed escalation and inadequate fluid monitoring
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.86 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high