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
533 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient barriers on elevated structures allowing jumps
Hammerson Plc · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Repeated catheterisation without oversight or documentation
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Delayed risk assessment documentation and missing exit assessments for self-harm
Greater Manchester Police · Police
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of dedicated substance misuse team in police custody
National Police Chiefs' Council · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of written observation protocol for child and adolescent mental health unit
Greater Manchester West Mental Health NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Unavailability of isoprenaline for heart transplant resuscitation
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of interpreter framework in healthcare settings
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Inappropriate use of intrapartum CTG guidance for antenatal monitoring
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Communication breakdown between junior doctor and consultant
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report