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
197 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo 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
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- 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 - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderate
- Lack of acute mental health inpatient beds
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
5 reports · 3 coronersClosely relatedConfidence 0.85 · 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
- Inadequate discharge medication risk assessment
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely 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 coronersClosely relatedConfidence 0.80 · moderateNo 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
- Insufficient ambulance resources leading to delayed response
South East Coast Ambulance Service · Ambulance service
4 reports · 3 coronersClosely relatedConfidence 0.85 · high