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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At least
337 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Incomplete paperwork and missing responsible clinician for section 5(2) holds
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Delayed mental health bed allocation leading to patient deterioration
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Insufficient probation officer staffing creates safety risks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Delay in obtaining timely imaging reports
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Lack of knowledge about emergency response codes and delayed staff training on
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of residential substance misuse treatment for under 18
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Unrecognised acute illness in resident
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Insufficient school nurse staffing weakens health education link
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Insufficient lighting at pedestrian refuge
National Highways · National body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inadequate ACCT training and supervision leading to observation failures
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report