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
666 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 - 3 reports · 2 coronersIdentical hazardConfidence 0.92 · high
- Inadequate information sharing between healthcare providers
Central and North West London NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate ACCT case management at HMP Woodhill
HMP Woodhill · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 8 reports · 6 coronersClosely relatedConfidence 0.80 · moderate
- Absence of in-cell automatic fire detection
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Young drivers carrying peer passengers increase collision risk
Department for Transport · National body
8 reports · 7 coronersClosely relatedConfidence 0.85 · highReviewed dossier - Insufficient inpatient bed capacity leading to delayed discharges and patient harm
Department of Health and Social Care · National body
26 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Gap in classification and remit leading to insufficient investigation
Metropolitan Police Service · Police
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 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 - Junior staff reluctance to challenge senior clinicians
East Suffolk and North Essex NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.93 · highNo published response to an earlier report
- Lack of mandatory ACCT training for agency staff
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of validated paediatric sepsis screening tool in emergency departments
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Inadequate shift handover communication leading to missed critical patient details
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high