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.
All chains
Organisation type
Theme
Relation
Reports
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Minimum confidence
At least
656 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Misinterpretation of centile chart guidance leading to delayed recognition of fe
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Incomplete investigation of patient observations
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Absence of mental health liaison during 72‑hour hold and missing discharge note
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Recurring hazard (see the quoted concerns)
Cornwall Council · Local authority
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Lack of understanding of required actions to prompt police progression
Metropolitan Police Service · Police
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 4 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Absence of learning disability liaison nurse support
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · high - Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Insufficient safeguards in long term opioid prescribing
Greater Manchester Integrated Care Board · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high