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 body175 Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health72 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:Confidence 0.80+Clear all

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

Restricted smoking options increase self-harm risk
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate record keeping of claimant interactions
Department for Work and Pensions · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Easy access to suicide instructions online and in print
Department for Culture · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Pedestrians crossing uncontrolled near bus stops
Department for Transport · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Insufficient anticoagulation guidance for immobilised patients
National Institute for Health and Care Excellence · National body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Inadequate verification of leave conditions
Coventry and Warwickshire Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Lack of clear protocol for managing sickle cell crises in prisons
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Absence of falls care plan
Barts Health NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
Home Office · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate clinical documentation of patient condition and decisions
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Missing person investigation lacks safe and well check
Metropolitan Police · Police
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Inadequate clinical records hinder investigations
Barking · Other
5 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inappropriate triage coding delays mental health ambulance response
Association of Ambulance Chief Executives · Ambulance service
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate out-of-hours psychiatric response and unsuitable section 136 suite
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Limited placement options for autistic young adults at risk of self-harm or harming others
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Ambulance handover delays due to bed shortages
Welsh Ambulance Service NHS Trust · Ambulance service
10 reports · 6 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Call handlers lack clinical training and rely on protocols
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Long waiting times for psychological assessment
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Recurring hazard (see the quoted concerns)
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high

All chains