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 body175 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:3+ reports Clear all

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

Lack of VTE risk assessment guidance
Department of Health and Social Care · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of electronic medical records sharing across trusts
NHS England · National body
5 reports · 5 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier
Governance failure in incident identification and poor quality of clinical notes
Barts Health NHS Trust · NHS body
3 reports · 1 coroner
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Governance failure in incident identification
Department of Health and Social Care · National body
4 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inaccurate or falsified patient observations
East London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate documentation of patient observations and assessments
Doncaster Royal Infirmary · Other
3 reports · 3 coroners
Closely relatedConfidence 0.86 · high
Inadequate record keeping leading to outdated patient information
Essex Partnership NHS Foundation Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Corridor patient care due to insufficient space
Department of Health and Social Care · National body
3 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Ambulance handover delays at emergency department
Aneurin Bevan University Health Board · NHS body
3 reports · 3 coroners
Identical hazardConfidence 0.90 · high
Delayed discharge due to insufficient social care placements
Greater Manchester Integrated Care · Other
4 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Uncontrolled import of harmful substances via online retailers
Home Office · National body
3 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Rigid MPDS questioning leads to under‑prioritisation of unconscious patients
London Ambulance Service NHS Trust · Ambulance service
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Public access to live rail at platform end
Network Rail · National body
16 reports · 14 coroners
Closely relatedConfidence 0.85 · highReviewed dossier
Inconsistent access to thrombectomy services
NHS England · National body
7 reports · 6 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED
Barts Health NHS Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Misrouting of domestic abuse reports leading to delayed welfare checks
Surrey Police · Police
3 reports · 3 coroners
Closely relatedConfidence 0.85 · high
Ambulance handover delay due to hospital capacity issues
Welsh Government · National body
4 reports · 4 coroners
Closely relatedConfidence 0.90 · high
Insufficient controls on reportable poison and explosives precursor
Home Office · National body
4 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete risk assessment before discharge
North East London Foundation Trust · NHS body
4 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Out-of-hours clinicians cannot access regular GP records
NHS England · National body
4 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

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