Window restrictors fail to prevent opening beyond 100mm
Department of Health and Social Care received 2 coroners' reports about this hazard between 8 Oct 2015 and 21 Jun 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“window restrictors may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“NHS England is spending £15m in 2016/17 to boost provision in those areas that need it most. This will include improving standards in existing places of safety to ensure that they are equipped to care for people safely and compassionately when detained under the Mental Health Act”
Stated timescale: 2016/17
- 8 years 8 months laterIdentical hazardConfidence 0.90 · higha different coroner
“window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm”
Original on judiciary.uk ↗ Repeated from the earlier report:windowrestrictorsinadequatepreventingdeterminedeffort
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2024Terrence Taylor8 years 8 months after Rebecca Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports identify that window restrictors can fail to stop a determined attempt to open a window past the 100 mm limit.
Rebecca Jones · 8 Oct 2015
“window restrictors may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction”
Original on judiciary.uk ↗ Terrence Taylor · 21 Jun 2024
“window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm”
Original on judiciary.uk ↗
Stated action · timescale: 2016/17
“NHS England is spending £15m in 2016/17 to boost provision in those areas that need it most. This will include improving standards in existing places of safety to ensure that they are equipped to care for people safely and compassionately when detained under the Mental Health Act”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2024 | 0.90 | 0.72 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.