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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At least
533 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Gap in classification and remit leading to insufficient investigation
Metropolitan Police Service · Police
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Delayed or missing clinical observations in pediatric emergency care
Royal College of Paediatrics and Child Health · National body
3 reports · 2 coronersClosely relatedConfidence 0.87 · high - Junior staff reluctance to challenge senior clinicians
East Suffolk and North Essex NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of mandatory ACCT training for agency staff
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of validated paediatric sepsis screening tool in emergency departments
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Inadequate shift handover communication leading to missed critical patient details
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed discharge increases infection risk for frail elderly patients
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of standard operating procedures for worsening patients in renal unit
Royal Cornwall Hospital · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of mandatory first aid and CPR training for prison officers
HMP Pentonville · Prison or detention
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 21 reports · 18 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 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 - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 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 - Insufficient information on gambling risks and unlicensed sites
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Inadequate ACCT training and knowledge gaps
Practice Plus Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.90 · high