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
18 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Sustained high operational pressure at REAP Level 4
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Ketamine misclassification as Class B drug
Home Office · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Insufficient safeguards in long term opioid prescribing
Greater Manchester Integrated Care Board · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inaccessible patient information across county boundaries
Surrey and Borders Partnership NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Lack of action on high clozapine blood test results
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Untrained police control room staff lack recognition of acute behaviour
College of Policing · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of joint access to NHS records by out of hours services
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Lack of clear protocol for repeated 999 calls and non-ambulance response
North East Ambulance Service NHS Foundation Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inadequate double check in controlled drug audit
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.92 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high