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.

Organisation type

Ambulance service25 Commissioner6 Company or provider10 Local authority28 National body342 NHS body Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health72 Products and workplaces9 Roads and rail53 Suicide197 Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:NHS body Confidence 0.80+Clear all

172 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete patient leave documentation
Lancashire Care NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delay in mental health act assessment
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Lack of internal review and investigation shortcomings
Manchester Mental Health NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate supervision and documentation of junior doctors
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Lack of formal mental health act assessment
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Communication failures between mental health liaison team and acute hospital
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Unnecessary patient transfers without proper documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Delayed patient location despite police assistance
Black Country Partnership NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Insufficient qualified nursing staff on surgical unit
Tameside General Hospital · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate record keeping and retention compromising care
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.82 · moderateNo published response to an earlier report
Lack of automated discharge medication notification to GP
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Lack of continuity of care due to excessive care team members
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 1 coroner
Identical hazardConfidence 0.92 · high
Lack of risk assessment documentation and updates
Pennine Acute Hospitals NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete handover documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
5 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Sequential treatment of dual diagnosis
Cornwall NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inadequate documentation hindering clinical communication
Tameside General Hospital · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Insufficient nighttime staffing leading to missed healthcare involvement in ACCT
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Missing admission risk assessments and care plan details
Avon and Wiltshire Mental Health NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate

All chains