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
656 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of staff training in cardiac arrest recognition and first aid
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Delayed emergency department treatment due to overcrowding
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high - Inadequate english proficiency hindering communication and safety
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inconsistent iv fluid administration and inadequate shock management
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.86 · high - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Shortage of autism-specific crisis care services
NHS England · National body
6 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Misinterpretation of CTG traces leading to missed abnormal fetal heart rate
Royal College of Obstetricians and Gynaecologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inconsistent interpretation of antenatal CTG leading to delayed response
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Online suicide method guides and forums
Department for Science · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high