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 body175 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 Suicide197 Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:Closely related Confidence 0.80+Clear all

533 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Missing prescription and fluid balance documentation
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Lack of VTE assessment and missing anticoagulation documentation
Worcestershire Acute Hospitals NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Pedestrian access to motorway via tunnel ramp and ladder
National Highways · National body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Risk assessment not updated with patient history
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Inappropriate speed limit on complex slip road
Gateshead Council · Local authority
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Misplaced nasogastric tubes in infants
Oxford University Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Lack of naloxone availability and training in prisons
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate investigation documentation and delayed safety disclosure
Care UK · Other
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Absence of lifejackets on vessels
Royal Yachting Association · Other
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of communication between specialties
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely 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 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate ACCT review for high-risk prisoners
Ministry of Justice · National body
5 reports · 5 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate risk information sharing and documentation
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of independence leads to non-disclosure fears
Ministry of Defence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Inadequate supervision of care coordinator role
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Restricted smoking options increase self-harm risk
NHS England · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Inadequate record keeping of claimant interactions
Department for Work and Pensions · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Easy access to suicide instructions online and in print
Department for Culture · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Pedestrians crossing uncontrolled near bus stops
Department for Transport · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

All chains