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 body Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health 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:NHS body Mental health Clear all

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

Inadequate documentation and communication of discharge decisions
South London and Maudsley NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate mental health team attendance at ACCT reviews
Oxleas NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Delay in prescribing and administering therapeutic medication for first episode
Essex Partnership NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Medication monitoring and discharge risk assessment failures
Pennine Care NHS Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete venous thromboembolism risk assessment
East London NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Inadequate multidisciplinary team meetings
Midlands Partnership NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed emergency response due to unclear call protocol
Nottinghamshire Healthcare NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate audit of observations and documentation
Greater Manchester Mental Health NHS Foundation Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incomplete patient leave documentation
Lancashire Care NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delay in mental health act assessment
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Delayed patient location despite police assistance
Black Country Partnership NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Sequential treatment of dual diagnosis
Cornwall NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inadequate record keeping compromising patient safety
Pennine Care NHS Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of discharge planning in mental health services
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Delay in declaring missing and informing police
Sussex Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incomplete care plan and risk assessment documentation
Sussex Partnership NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of written observation protocol for child and adolescent mental health unit
Greater Manchester West Mental Health NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Discharge without follow up arrangements
South London and Maudsley NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

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