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
52 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient swimming education leading to drowning in open water
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of regular allergy review
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo 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 - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Critical clinical information lost during verbal handover
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Insufficient probation officer staffing creates safety risks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Insufficient school nurse staffing weakens health education link
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inadequate street lighting at junction
Warwickshire County Council · Local authority
5 reports · 4 coronersClosely relatedConfidence 0.86 · high - Unsupervised minors and inaccurate attendance data at Leeds Festival
Leeds City Council · Local authority
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Lack of integrated multidisciplinary care across sites
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inadequate training for firearms licensing staff
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Missing training records and qualifications verification
Leeds Teaching Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 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 coronersClosely relatedConfidence 0.80 · moderate