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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Theme
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At least
543 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Insufficient probation officer staffing creates safety risks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Delay in obtaining timely imaging reports
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Delayed escalation and inadequate fluid monitoring
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed ambulance handover leading to unavailability
Aneurin Bevan University Health Board · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of knowledge about emergency response codes and delayed staff training on
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unrecognised acute illness in resident
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Restricted access to treatment for borderline personality disorder
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.70 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.78 · moderate
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.86 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report