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:Confidence 0.90+Clear all

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

Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Lack of information sharing between online prescribing services and GP systems
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
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
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
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
Missing call logging system for prisoner welfare
Ministry of Justice · National body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · highNo 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 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 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
Inadequate verification of leave conditions
Coventry and Warwickshire Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Absence of falls care plan
Barts Health NHS Trust · NHS body
3 reports · 3 coroners
Closely 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 coroners
Closely relatedConfidence 0.90 · high

All chains