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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16 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 55 reports · 32 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate risk assessment documentation and inaccurate record keeping
Essex Partnership University NHS Foundation Trust · NHS body
6 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of basic first aid training and CPR among prison officers
His Majesty's Prison and Probation Service · National body
12 reports · 12 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier - Inadequate ACCT training leading to incomplete documentation
His Majesty's Prison and Probation Service · National body
16 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Insufficient inpatient bed capacity leading to delayed discharges and patient harm
Department of Health and Social Care · National body
26 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 21 reports · 18 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Non‑compliance with care plans and insufficient incident review
Care Quality Commission · National body
5 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 5 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier
- Public access to live rail at platform end
Network Rail · National body
16 reports · 14 coronersClosely relatedConfidence 0.85 · highReviewed dossier - 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 - 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 - 5 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Physical health check delays mental health referrals
Norfolk and Suffolk NHS Foundation Trust · NHS body
5 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 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