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 body 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:NHS body Hospital care Clear all

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

Delayed escalation and inadequate fluid monitoring
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate documentation of clinical decisions
Barts Health NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of family involvement in crisis care
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Incomplete patient information documentation
Lancashire Teaching Hospitals · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Unavailable bed leading to delayed patient transfer
University College London Hospitals NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Fragmented transfer information across records
University Hospitals of Derby and Burton · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate nursing staffing affecting wound care and fall prevention
Aneurin Bevan University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of formal mental health act assessment
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Communication failures between mental health liaison team and acute hospital
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 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
Insufficient qualified nursing staff on surgical unit
Tameside General Hospital · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo 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 continuity of care due to excessive care team members
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 1 coroner
Identical hazardConfidence 0.92 · high
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 documentation hindering clinical communication
Tameside General Hospital · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Incompatible IT systems hinder clinical information exchange
Stockport NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate family communication and documentation
South London and Maudsley NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.78 · moderateNo published response to an earlier report
Nursing care inadequacy
United Lincolnshire Hospitals NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

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