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.

Marac system ineffective for chaotic victims
Home Office · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.80 · moderate
Converging surface water on A390 near Coliza Hill
Cornwall Council and CORMAC · Local authority
2 reports · 1 coroner
Identical hazardConfidence 0.98 · high
Lack of nighttime visual monitoring of vulnerable individual
Care Quality Commission · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Delayed symptom recognition leading to missed emergency response
London Ambulance Service NHS Trust · Ambulance service
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Missing medication documentation
Royal London Hospital · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate warning signage at junction
Cumbria County Council · Local authority
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Mental health disclosure not distinguished from disability in UCAS application
Universities and Colleges Admissions Service · Other
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Lack of duty lawyer access for foreign national prisoners
Home Office · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Absence of cardiotocography monitoring in maternity settings
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of training on eating disorders and MARSIPAN implementation
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.95 · high
Premature discharge from community mental health services
Kernow Clinical Commissioning Group · Commissioner
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Inadequate supervision of junior medical staff
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.86 · high
Inadequate assessment before remote psychotropic prescribing
General Medical Council · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Lack of centralised prescription database
Department of Health and Social Care · National body
2 reports · 2 coroners
Identical hazardConfidence 0.95 · highNo published response to an earlier report
Uncontrolled prescribing of contraindicated drugs
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.95 · high
Manipulable medication suitability questionnaire
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of suicide risk assessment after discharge
East London NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high

All chains