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
19 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersIdentical hazardConfidence 0.95 · high
- Insufficient patient observation leading to inpatient falls
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Fragmented communication between mental and physical health services
Southern Health NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Governance failure in incident identification and poor quality of clinical notes
Barts Health NHS Trust · NHS body
3 reports · 1 coronerIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Delayed sepsis recognition and treatment
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- Inaccessible patient information across county boundaries
Surrey and Borders Partnership NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Lack of continuity of care due to excessive care team members
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 1 coronerIdentical hazardConfidence 0.92 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Lack of inpatient mental health beds
Avon and Wiltshire Mental Health Partnership NHS Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 1 coronerIdentical hazardConfidence 0.95 · high