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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Theme
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At least
18 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Overly rigid right care right person policy leading to deployment delays
College of Policing · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · high - Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inadequate training for police and ambulance crew on acute behavioural distress
Association of Ambulance Chief Executives · Ambulance service
5 reports · 5 coronersClosely relatedConfidence 0.85 · high - Widespread new psychoactive substances in prison
His Majesty's Prison and Probation Service · National body
5 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate clinical documentation hindering patient care understanding
Manchester University NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo 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 - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.90 · high - Unlicensed DNP weight loss drug toxicity
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Inadequate audit of observations and documentation
Greater Manchester Mental Health NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Poor record keeping in missing person investigations
Department of Health and Social Care · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - Lack of assistance for individuals with addictions and mental health difficulty
Change Grow Live · Other
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of written observation protocol for child and adolescent mental health unit
Greater Manchester West Mental Health NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report