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
70 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of follow-up on mental health history and drug overdose
Practice Plus Group · Company or provider
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Untrained staff conducting mental health assessments
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.92 · high - Lack of basic first aid training and CPR among prison officers
His Majesty's Prison and Probation Service · National body
12 reports · 12 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier - Inadequate weekend mental health provision at prison
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Inadequate ACCT case management at HMP Woodhill
HMP Woodhill · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of mandatory first aid and CPR training for prison officers
HMP Pentonville · Prison or detention
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Inadequate ACCT training and knowledge gaps
Practice Plus Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 5 reports · 5 coronersClosely 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 coronersClosely relatedConfidence 0.92 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Inadequate transition pathway from CAMHS to adult services
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Insufficient mental health beds leading to ED psychiatric patient detention
South West London Integrated Care Board · Commissioner
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high