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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Organisation type
Theme
Relation
Reports
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Minimum confidence
At least
64 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- 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 - 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo 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 - Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 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 - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - 5 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report