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.
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Organisation type
Theme
Relation
Reports
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Minimum confidence
At least
150 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Shortage of autism-specific crisis care services
NHS England · National body
6 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Misinterpretation of CTG traces leading to missed abnormal fetal heart rate
Royal College of Obstetricians and Gynaecologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Incorrect section placement and missing information during assessments
Birmingham City Council · Local authority
3 reports · 1 coronerClosely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Insufficient ambulance availability leading to delayed response
Department of Health and Social Care · National body
7 reports · 7 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 7 reports · 7 coronersClosely relatedConfidence 0.80 · moderateReviewed dossier
- Inability to access GP medication records across systems
Essex Partnership University NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 5 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high