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 body 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 Suicide Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:NHS body Suicide Clear all

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

Inadequate discharge medication risk assessment
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete or inaccurate transfer of care documentation
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Police response uncertainty in mental health emergencies
East London NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate transfer of suicide risk information
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delays in investigating adverse incidents and implementing actions
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Missing hot debrief documentation after incident
East London NHS Foundation Trust · NHS body
2 reports · 1 coroner
Identical hazardConfidence 0.90 · high
Staff unawareness of observation requirements
Norfolk and Suffolk NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.80 · moderate
Lack of suicide risk assessment after discharge
East London NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Overdue CPA meetings and missing discharge care plans
Oxford Health NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of lead practitioner during transfer leading to lost follow up
Sussex Partnership NHS Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of communication and care coordination in placement decisions
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of internal review and investigation shortcomings
Manchester Mental Health NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate supervision and documentation of junior doctors
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Insufficient nighttime staffing leading to missed healthcare involvement in ACCT
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Missing admission risk assessments and care plan details
Avon and Wiltshire Mental Health NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Delayed resolution of outstanding safety issues
Avon and Wiltshire Mental Health Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Reliance on informal assurances leading to missed referrals
Pennine Care NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inappropriate referral to Healthy Minds for complex PTSD
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

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