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
99 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient mental health beds leading to ED psychiatric patient detention
South West London Integrated Care Board · Commissioner
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unrestricted domestic purchase of substance
Home Office · National body
2 reports · 1 coronerIdentical hazardConfidence 0.96 · high - Delayed staff training on cell entry and emergency communications
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 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 - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Online suicide method guides and forums
Department for Science · National body
2 reports · 2 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 - 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Lack of information sharing between online prescribing services and GP systems
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 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 - Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report