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 risk assessment documentation and inaccurate record keeping
Essex Partnership University NHS Foundation Trust · NHS body
6 reports · 4 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate medical documentation in acute trust
Mid and South Essex NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Untrained staff conducting mental health assessments
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.92 · high
Inadequate ACCT documentation and communication
Central and North West London NHS Foundation Trust · NHS body
4 reports · 3 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate discharge decision analysis
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Assumption about capacity context
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of allocated care coordinator and psychiatric nurse appointments
North Staffordshire Combined Healthcare NHS trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.86 · high
Fragmented communication between mental and physical health services
Southern Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Inaccurate or falsified patient observations
East London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate record keeping leading to outdated patient information
Essex Partnership NHS Foundation Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Incomplete investigation of patient observations
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Absence of mental health liaison during 72‑hour hold and missing discharge note
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderate
Inadequate discharge planning processes
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incomplete risk assessment before discharge
North East London Foundation Trust · NHS body
4 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Inadequate transfer assessment and documentation
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate support for autistic prisoners in crisis
Devon Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Risk of suicide in mental health care
Midlands Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.85 · high
Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of medication monitoring after clinic visit
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate

All chains