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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26 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Inconsistent access to thrombectomy services
NHS England · National body
7 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Insufficient safeguards in long term opioid prescribing
Greater Manchester Integrated Care Board · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Delayed ambulance response due to missed urgency recognition
North East Ambulance Service NHS Foundation Trust · Ambulance service
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of communication between hospital and care home regarding mental capacity
Surrey County Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of action on high clozapine blood test results
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Look-alike medication packaging leading to dispensing errors
Medicines and Healthcare products Regulatory Agency · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- 4 reports · 4 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 - Delayed symptom recognition leading to missed emergency response
London Ambulance Service NHS Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate