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
57 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of regular first aid training among custodial staff
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
- 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 - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · 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 - Delayed ACCT case review and inadequate process management
Practice Plus Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 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 - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Inappropriate prison environment for mental health treatment
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Delay in prescribing and administering therapeutic medication for first episode
Essex Partnership NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Lack of understanding of required actions to prompt police progression
Metropolitan Police Service · Police
2 reports · 2 coronersClosely relatedConfidence 0.85 · 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 - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely 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