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
90 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Missed opportunity for appropriate VTE risk management
Worcestershire Acute Hospitals NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Communication failures and information sharing problems across trust
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Antibiotic prescribing without joint discussion or swallow assessment
Tameside General Hospital · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Delayed referral for neurosurgical care
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Ambulance crew waiting in corridor due to insufficient clinical space
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed resuscitation due to insufficient staff awareness or training
Oxleas NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Maternal heart rate misinterpreted as fetal heart rate
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 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 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 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 - Delayed discharge increases infection risk for frail elderly patients
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of standard operating procedures for worsening patients in renal unit
Royal Cornwall Hospital · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersClosely relatedConfidence 0.86 · high
- 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report