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
175 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of standard operating procedures for worsening patients in renal unit
Royal Cornwall Hospital · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Lack of allocated care coordinator and psychiatric nurse appointments
North Staffordshire Combined Healthcare NHS trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.86 · 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 · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 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
- Inadequate record keeping leading to outdated patient information
Essex Partnership NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Delay in prescribing and administering therapeutic medication for first episode
Essex Partnership NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED
Barts Health NHS Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Incomplete investigation of patient observations
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Absence of mental health liaison during 72‑hour hold and missing discharge note
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate