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
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Reports
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Minimum confidence
At least
16 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Gap in classification and remit leading to insufficient investigation
Metropolitan Police Service · Police
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 4 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Contraband mobile phones enabling drug misuse
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed ambulance call for medical distress
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of naloxone availability and training in prisons
NHS England · National body
2 reports · 2 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 - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Absence of breathing guard during mouth to mouth resuscitation
His Majesty's Prison and Probation Service · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - SASH form not identified or completed at reception
HMP Winchester · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Risk of suicide and self-harm in newly arrived prisoners
His Majesty's Prison and Probation Service · National body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inadequate staff training and understanding of ACCT protocol
HMP Pentonville · Prison or detention
2 reports · 1 coronerClosely relatedConfidence 0.90 · high