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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Organisation type
Theme
Relation
Reports
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Minimum confidence
At least
175 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of communication and care coordination in placement decisions
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate supervision and documentation of junior doctors
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely 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 coronerClosely relatedConfidence 0.85 · high - Unnecessary patient transfers without proper documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely 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 coronersClosely relatedConfidence 0.82 · moderateNo published response to an earlier report - Lack of automated discharge medication notification to GP
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of continuity of care due to excessive care team members
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 1 coronerIdentical hazardConfidence 0.92 · high - 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 5 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate