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
13 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Unclear wording in NHS Pathways triage questions
NHS England · National body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Young drivers carrying peer passengers increase collision risk
Department for Transport · National body
8 reports · 7 coronersClosely relatedConfidence 0.85 · highReviewed dossier - Delayed or missing clinical observations in pediatric emergency care
Royal College of Paediatrics and Child Health · National body
3 reports · 2 coronersClosely relatedConfidence 0.87 · high - Inaccurate post mortem sampling in suspected anaphylaxis cases
Royal College of Pathologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 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 - 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 - 5 reports · 5 coronersClosely relatedConfidence 0.90 · 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 - 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of regular allergy review and named accountability for allergy services
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Inadequate street lighting at junction
Warwickshire County Council · Local authority
5 reports · 4 coronersClosely relatedConfidence 0.86 · high - Inadequate face to face medical handover of patient information
Care Quality Commission · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Incomplete and inaccurate nursing records and documentation
Pennine Acute Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.85 · high