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:Closely related Confidence 0.80+Clear all

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

Delayed ambulance handover leading to unavailability
Aneurin Bevan University Health Board · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of knowledge about emergency response codes and delayed staff training on
His Majesty's Prison and Probation Service · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate documentation of clinical decisions
Barts Health NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Unrecognised acute illness in resident
Care Quality Commission · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of family involvement in crisis care
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Delayed neurology outpatient appointments increase SUDEP risk
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate fencing allowing unauthorized railway access
British Transport Police · National body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · high
Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coroners
Closely relatedConfidence 0.86 · highNo published response to an earlier report
Delayed referral to vascular services
Greater Manchester Integrated Care · Other
2 reports · 1 coroner
Closely relatedConfidence 0.86 · high
Lack of age verification allowing children unrestricted content access
Media and Sport · Other
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Lack of staff awareness and audit of home leave policy
Nottinghamshire Healthcare NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Lack of multidisciplinary coordination of care
Northumberland · Other
3 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate multidisciplinary team meetings
Midlands Partnership NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed ambulance dispatch due to insufficient resources
Welsh Government · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Ambulance not called promptly when person reported dead
Greater Manchester Police · Police
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Insufficient school nurse staffing weakens health education link
Department for Education · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of mandatory first aid training for care home carers
Care Quality Commission · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Excessive waiting time for psychotherapy
Department of Health and Social Care · National body
6 reports · 5 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Delayed ambulance response due to missed urgency recognition
North East Ambulance Service NHS Foundation Trust · Ambulance service
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

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