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
108 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.78 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of contingency planning for patient departure
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of timely crisis team visits and communication
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Delayed mental health assessment in emergency unit
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Inaccurate early warning score calculation by clinical staff
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate patient information handover between care settings
Manchester Clinical Commissioning Group · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inconsistent discharge policy application
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Chest drain insertion without pre-procedure checks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Inadequate communication between clinical staff and families
Tameside Hospital NHS Foundation Trust · NHS body
4 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerIdentical hazardConfidence 0.95 · high
- Lack of discharge communication and coordinated care planning
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of care coordinator for continuity of support
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Insufficient tissue viability nursing staffing leading to delayed wound care
Cwm Taf University Health Board · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · highNo published response to an earlier report