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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137 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Incorrect section placement and missing information during assessments
Birmingham City Council · Local authority
3 reports · 1 coronerClosely relatedConfidence 0.85 · highNo published response to an earlier report - 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 - Insufficient ambulance availability leading to delayed response
Department of Health and Social Care · National body
7 reports · 7 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 7 reports · 7 coronersClosely relatedConfidence 0.80 · moderateReviewed dossier
- Inability to access GP medication records across systems
Essex Partnership University NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · 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 - Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 5 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo 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 - 5 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Ambulance handover delays due to bed shortages
Welsh Ambulance Service NHS Trust · Ambulance service
10 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Physical health check delays mental health referrals
Norfolk and Suffolk NHS Foundation Trust · NHS body
5 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of regular allergy review and named accountability for allergy services
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Welfare checks missed and undocumented
HMP Swaleside · Prison or detention
3 reports · 1 coronerClosely relatedConfidence 0.90 · high