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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Organisation type
Theme
Relation
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Minimum confidence
At least
100 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate communication of SSRI suicide risk
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.85 · high - 2 reports · 2 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
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Restricted smoking options increase self-harm risk
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Limited placement options for autistic young adults at risk of self-harm or harming others
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Detention without section due to bed shortage
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Medical information not disclosed to firearms licensing authority
National Police Chiefs' Council · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Incomplete or meaningless ACCT observations in prison
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed bespoke care placement arrangements
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Incomplete paperwork and missing responsible clinician for section 5(2) holds
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high