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
167 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Public access to live rail at platform end
Network Rail · National body
16 reports · 14 coronersClosely relatedConfidence 0.85 · highReviewed dossier - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Incomplete investigation of patient observations
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Absence of mental health liaison during 72‑hour hold and missing discharge note
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Recurring hazard (see the quoted concerns)
Cornwall Council · Local authority
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 4 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 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 - Shortage of autism-specific crisis care services
NHS England · National body
6 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo 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 medication monitoring after clinic visit
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 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