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
24 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Obscured observation panels hinder monitoring
His Majesty's Prison and Probation Service · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 16 reports · 13 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Absence of in-cell automatic fire detection
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo 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 - Inadequate medical information transfer between custodial healthcare providers
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- Delayed ambulance call for medical distress
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Lack of naloxone availability and training in prisons
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Absence of fitness to transfer assessment
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Absence of breathing guard during mouth to mouth resuscitation
His Majesty's Prison and Probation Service · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Cancellation of hospital appointments for prisoners
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high