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 care 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:Hospital care Closely related Clear all

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

Delayed surgery beyond 36 hours
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Misplaced central venous line
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
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
Delayed transfer of hip fracture patients to inpatient care
NHS England · National body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Incomplete employment history for long term locum doctors
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Undeclared allergens leading to anaphylaxis in food businesses
Food Standards Agency · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Fragmented transfer information across records
University Hospitals of Derby and Burton · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Forgotten biliary stent without registry
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate supervision of junior medical staff
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.86 · high
Inadequate handover of clinical information between wards
General Medical Council · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate nursing staffing affecting wound care and fall prevention
Aneurin Bevan University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete patient transfer information
NHS England · National body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Lack of formal mental health act assessment
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Communication failures between mental health liaison team and acute hospital
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Unnecessary patient transfers without proper documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Insufficient qualified nursing staff on surgical unit
Tameside General Hospital · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate record keeping and retention compromising care
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.82 · moderateNo published response to an earlier report
Lack of risk assessment documentation and updates
Pennine Acute Hospitals NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

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