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:Closely related Clear all

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

Correspondence not reaching medical staff
Croft Shifa Health Centre · Other
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of acute mental health inpatient beds
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
5 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Delayed surgery beyond 36 hours
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate risk assessment for self-harm patients
Sheffield Health and Social Care NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Excessive ambulance handover delays at hospitals
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Misplaced central venous line
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate street lighting at junction
Warwickshire County Council · Local authority
5 reports · 4 coroners
Closely relatedConfidence 0.86 · high
Delayed and ineffective incident investigations by managers
Care Quality Commission · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of rolling risk assessment documentation in SystemOne
Birmingham and Solihull Mental Health Foundation · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate discharge medication risk assessment
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine · National body
3 reports · 3 coroners
Closely relatedConfidence 0.86 · highNo published response to an earlier report
Incomplete or inaccurate transfer of care documentation
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate CAMHS resources amid rising demand
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Unsupervised minors and inaccurate attendance data at Leeds Festival
Leeds City Council · Local authority
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inadequate signage at junction leading to visibility issues
Lincolnshire County Council · Local authority
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Absence of on-site defibrillator during training
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Ambulance delays for frail elderly hip fracture patients
Department of Health and Social Care · National body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Delayed transfer of hip fracture patients to inpatient care
NHS England · National body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Inadequate communication between health care departments
NHS Digital · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high

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