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
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At least
37 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of regular first aid training among custodial staff
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 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
- Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Lack of audit and standard care plan implementation
The Priory Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 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 hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Inadequate audit of observations and documentation
Greater Manchester Mental Health NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed ambulance response to patient deterioration
East of England Ambulance Service · Ambulance service
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high