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.

Organisation type

Ambulance service25 Commissioner6 Company or provider10 Local authority28 National body342 NHS body175 Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health72 Products and workplaces9 Roads and rail53 Suicide197 Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

666 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Online suicide forum encourages self-harm and suicide methods
Media and Sport · Other
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate ACCT training and supervision leading to observation failures
His Majesty's Prison and Probation Service · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Overcrowded emergency department leading to delays
Department of Health and Social Care · National body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · high
Missing prior suicide attempt information
Devon Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incomplete risk assessment documentation and communication
Devon Partnership NHS Trust · NHS body
4 reports · 4 coroners
Closely relatedConfidence 0.80 · moderate
Unavailable bed leading to delayed patient transfer
University College London Hospitals NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Correspondence not reaching medical staff
Croft Shifa Health Centre · Other
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of acute mental health inpatient beds
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
5 reports · 3 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Delayed surgery beyond 36 hours
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate risk assessment for self-harm patients
Sheffield Health and Social Care NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of automated medication compliance alerts
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.92 · highNo published response to an earlier report
Inadequate paramedic ECG interpretation training
Health and Care Professions Council · Local authority
2 reports · 2 coroners
Identical hazardConfidence 0.92 · high
Excessive ambulance handover delays at hospitals
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Misplaced central venous line
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate street lighting at junction
Warwickshire County Council · Local authority
5 reports · 4 coroners
Closely relatedConfidence 0.86 · high
Continuing medication for VTE risk after discharge
National Institute for Health and Care Excellence · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Absence of fitness to transfer assessment
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo published response to an earlier report
Delay in reporting original x-ray findings to clinicians
Department of Health and Social Care · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Delayed and ineffective incident investigations by managers
Care Quality Commission · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of rolling risk assessment documentation in SystemOne
Birmingham and Solihull Mental Health Foundation · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high

All chains