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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Organisation type
Theme
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At least
337 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient family involvement in mental health care processes
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of mental health service connection by probation officers
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate inter-agency communication about risk and urgency
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Cancellation of hospital appointments for prisoners
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.96 · high
- Lack of public access to adrenaline auto-injectors
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inadequate risk assessment documentation and undocumented risk disclosures
Ministry of Defence · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Incomplete patient transfer information
NHS England · National body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Insufficient visibility of pedestrians near stationary lorries
Department for Transport · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of joint access to NHS records by out of hours services
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 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
- 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Self certification enables unsafe drug access
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Misunderstanding of section 135 mental health act powers leading to delays
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate adrenaline dose in autoinjectors
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Inadequate audit of 111 call errors
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report