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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Organisation type
Theme
Relation
Reports
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Minimum confidence
At least
666 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of care plan coordination
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of meaningful family involvement in care process
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Inadequate information sharing between mental health and substance misuse teams
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inaccurate discharge letters to primary care
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - SASH form not identified or completed at reception
HMP Winchester · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Inadequate allergy action plan communication in school
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.88 · high - Inadequate record keeping and retention compromising care
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.82 · moderateNo published response to an earlier report - Vegetation encroaching on carriageway leading to pedestrian hazard
Kent County Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Lack of automated discharge medication notification to GP
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of continuity of care due to excessive care team members
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 1 coronerIdentical hazardConfidence 0.92 · high