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
337 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Overcrowded emergency department leading to delays
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · high - Delayed surgery beyond 36 hours
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Lack of automated medication compliance alerts
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Continuing medication for VTE risk after discharge
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Absence of fitness to transfer assessment
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Delay in reporting original x-ray findings to clinicians
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine · National body
3 reports · 3 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Incompatible electronic records between mental and physical health services
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high - Ambulance delays for frail elderly hip fracture patients
Department of Health and Social Care · National body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 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 - Untrained police control room staff lack recognition of acute behaviour
College of Policing · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-cool
UK Health Security Agency · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high