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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Theme
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Minimum confidence
At least
533 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delayed ACCT case review and inadequate process management
Practice Plus Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Lack of certified safer cells outside segregation unit
His Majesty's Prison and Probation Service · National body
4 reports · 4 coronersClosely relatedConfidence 0.80 · moderate - Widespread new psychoactive substances in prison
His Majesty's Prison and Probation Service · National body
5 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 4 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Illicit drug availability in prisons
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.85 · highNo published response to an earlier report - Contraband mobile phones enabling drug misuse
Ministry of Justice · 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 · 1 coronerClosely relatedConfidence 0.85 · high
- Inaccurate post mortem sampling in suspected anaphylaxis cases
Royal College of Pathologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Inappropriate prison environment for mental health treatment
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of allocated care coordinator and psychiatric nurse appointments
North Staffordshire Combined Healthcare NHS trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.86 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Inadequate medical assessment of drivers' health conditions
Driver and Vehicle Licensing Agency · National body
4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of specialised personality disorder services
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Inadequate medical information transfer between custodial healthcare providers
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high