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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At least
56 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 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 - Missed breech presentation due to lack of routine prenatal scanning
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - Lack of timely crisis team visits and communication
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Inadequate patient information handover between care settings
Manchester Clinical Commissioning Group · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inconsistent discharge policy application
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerIdentical hazardConfidence 0.95 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unavailability of isoprenaline for heart transplant resuscitation
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of interpreter framework in healthcare settings
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Communication breakdown between junior doctor and consultant
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report