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
56 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 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 - Shortage of tier 4 paediatric mental health beds
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- 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 · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- 2 reports · 1 coronerClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate transition pathway from CAMHS to adult services
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unrestricted domestic purchase of substance
Home Office · National body
2 reports · 1 coronerIdentical hazardConfidence 0.96 · high - Delayed staff training on cell entry and emergency communications
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- Online suicide method guides and forums
Department for Science · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical 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 coronersClosely relatedConfidence 0.90 · high - Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high