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.
All chains
Organisation type
Theme
Relation
Reports
More filters
Minimum confidence
At least
45 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delay in obtaining timely imaging reports
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Delayed surgery beyond 36 hours
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Continuing medication for VTE risk after discharge
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine · National body
3 reports · 3 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · 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 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.86 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Incomplete patient transfer information
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of national guidelines for post-procedure monitoring after nerve block
Royal College of Surgeons · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Missed breech presentation due to lack of routine prenatal scanning
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - Inaccurate early warning score calculation by clinical staff
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Chest drain insertion without pre-procedure checks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Repeated catheterisation without oversight or documentation
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report