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
342 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient mental health resources for children and young people
Department of Health and Social Care · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unrestricted sale of helium gas canisters
Home Office · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Poor record keeping in missing person investigations
Department of Health and Social Care · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - Inadequate seizure recognition and post‑seizure behaviour training
College of Policing · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Marac system ineffective for chaotic victims
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 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 - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Absence of cardiotocography monitoring in maternity settings
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersIdentical hazardConfidence 0.95 · high
- Outdated care plan and risk assessment
Ministry of Defence · National body
2 reports · 2 coronersClosely relatedConfidence 0.78 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.86 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.95 · highNo published response to an earlier report
- Uncontrolled prescribing of contraindicated drugs
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high