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
175 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delays in investigating adverse incidents and implementing actions
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- Lack of risk assessment for missing persons
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate audit of observations and documentation
Greater Manchester Mental Health NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inconsistent medication quantity documentation and unrecorded stock
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Missing training records and qualifications verification
Leeds Teaching Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Unclear discharge responsibility and lack of named consultant review prior to pa
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of serious incident review and mandatory root cause analysis training
University Hospital of North Midlands · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of lead practitioner during transfer leading to lost follow up
Sussex Partnership NHS Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate nursing staffing affecting wound care and fall prevention
Aneurin Bevan University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high