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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At least
193 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed bespoke care placement arrangements
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Incomplete paperwork and missing responsible clinician for section 5(2) holds
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Lack of post discharge support for high risk patients
Leicestershire Partnership NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Delayed mental health bed allocation leading to patient deterioration
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inadequate resuscitation training clarity
HMP Wandsworth · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of knowledge about emergency response codes and delayed staff training on
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersClosely 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 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report