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
666 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of joint access to NHS records by out of hours services
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Pedestrians crossing unlit dual carriageway at 60mph speed limit
Durham County Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of communication and care coordination in placement decisions
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Self certification enables unsafe drug access
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Ambulance resource shortage delays urgent patient transfers
East Midlands Ambulance Service · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Misunderstanding of section 135 mental health act powers leading to delays
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Inadequate adrenaline dose in autoinjectors
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Inadequate audit of 111 call errors
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report