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
19 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of basic first aid training and CPR among prison officers
His Majesty's Prison and Probation Service · National body
12 reports · 12 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier - Inadequate weekend mental health provision at prison
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of mandatory first aid and CPR training for prison officers
HMP Pentonville · Prison or detention
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 5 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Welfare checks missed and undocumented
HMP Swaleside · Prison or detention
3 reports · 1 coronerClosely relatedConfidence 0.90 · high - Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 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 - 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Missing escort records during reception screening
His Majesty's Prison and Probation Service · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report