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
137 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Inadequate record keeping leading to outdated patient information
Essex Partnership NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Rigid MPDS questioning leads to under‑prioritisation of unconscious patients
London Ambulance Service NHS Trust · Ambulance service
3 reports · 2 coronersClosely 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 coronersClosely relatedConfidence 0.85 · highReviewed dossier - Inconsistent access to thrombectomy services
NHS England · National body
7 reports · 6 coronersClosely 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 coronersClosely relatedConfidence 0.80 · moderate - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 4 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo 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 - 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Shortage of autism-specific crisis care services
NHS England · National body
6 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Misinterpretation of CTG traces leading to missed abnormal fetal heart rate
Royal College of Obstetricians and Gynaecologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report