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 care108 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 Clear all

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

Incomplete risk assessment before discharge
North East London Foundation Trust · NHS body
4 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Lack of strategic governance hindering incident identification
Barts Health NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate transfer assessment and documentation
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate support for autistic prisoners in crisis
Devon Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Risk of suicide in mental health care
Midlands Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · high
Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Discharge without surgical review or sepsis recognition
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of medication monitoring after clinic visit
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Missing radiology discussion records for children
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inability to access GP medication records across systems
Essex Partnership University NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Delayed access to medical records
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.92 · highNo published response to an earlier report
Missing prescription and fluid balance documentation
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of VTE assessment and missing anticoagulation documentation
Worcestershire Acute Hospitals NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Risk assessment not updated with patient history
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Misplaced nasogastric tubes in infants
Oxford University Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate supervision of care coordinator role
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate verification of leave conditions
Coventry and Warwickshire Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high

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