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 body NHS body175 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:National body Suicide Clear all

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

Insufficient mental health resources for children and young people
Department of Health and Social Care · National body
4 reports · 4 coroners
Closely relatedConfidence 0.85 · high
Inadequate bridge safety measures leading to suicides
National Highways · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Unrestricted sale of helium gas canisters
Home Office · National body
2 reports · 2 coroners
Identical hazardConfidence 0.95 · high
Marac system ineffective for chaotic victims
Home Office · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Lack of duty lawyer access for foreign national prisoners
Home Office · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Outdated care plan and risk assessment
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.78 · moderate
Cable ties compromising fence integrity
British Transport Police · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Insufficient family involvement in mental health care processes
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of mental health service connection by probation officers
His Majesty's Prison and Probation Service · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate risk assessment documentation and undocumented risk disclosures
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Self certification enables unsafe drug access
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.96 · high
Inconsistent mental health service provision for 16-18 year olds
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of meaningful family involvement in care process
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate family involvement in care
Department of Health and Social Care · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Inadequate information sharing between mental health and substance misuse teams
NHS England · National body
2 reports · 2 coroners
Identical hazardConfidence 0.92 · highNo published response to an earlier report
Inadequate signage and lighting at foot crossing
Network Rail · National body
4 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Unclear hospital transfer process and forms
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Missing escort records during reception screening
His Majesty's Prison and Probation Service · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate CCTV monitoring in custodial settings
Ministry of Justice · National body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · highNo published response to an earlier report

All chains