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.
All chains
Organisation type
Theme
Relation
Reports
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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.
- Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Delayed mental health bed allocation leading to patient deterioration
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Lack of knowledge about emergency response codes and delayed staff training on
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inadequate ACCT training and supervision leading to observation failures
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of automated medication compliance alerts
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Incompatible electronic records between mental and physical health services
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Unattended blade in cell overnight
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Missing mental health assessment in police custody
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - Healthcare staff absent during ACCT reviews
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of coordinated support for vulnerable adults with complex needs
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high