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 0.90+Clear all

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

Lack of VTE risk assessment guidance
Department of Health and Social Care · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate foreign body management guidance
Nottinghamshire Healthcare NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of electronic medical records sharing across trusts
NHS England · National body
5 reports · 5 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier
Indefinite imprisonment without clear release pathway
His Majesty's Prison and Probation Service · National body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Limited access to police national database by front line officers
Home Office · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Governance failure in incident identification
Department of Health and Social Care · National body
4 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inadequate obstetric emergency training for paramedics
Association of Ambulance Chief Executives · Ambulance service
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of anti choking devices in care homes and restaurants
Health and Safety Executive · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Insufficient police resources to respond to critical calls
Home Office · National body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Lack of national interface for safeguarding record keeping
Department for Education · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inaccurate or falsified patient observations
East London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate transition pathway from CAMHS to adult services
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Insufficient mental health beds leading to ED psychiatric patient detention
South West London Integrated Care Board · Commissioner
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Unregulated lithium-ion batteries in e-bike conversions
Department for Business and Trade · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed discharge due to insufficient social care placements
Greater Manchester Integrated Care · Other
4 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Uncontrolled import of harmful substances via online retailers
Home Office · National body
3 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed ambulance call for medical distress
Ministry of Justice · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Delayed entry to residence due to underestimated urgency
Greater Manchester Police · Police
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate discharge planning processes
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Raised obstruction on road surface leading to loss of control
National Highways · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high

All chains