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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Theme
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At least
202 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient social care provision leading to discharge delays
Department of Health and Social Care · National body
8 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Obscured observation panels hinder monitoring
His Majesty's Prison and Probation Service · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Delayed referral for neurosurgical care
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Missing pedestrian crossing on busy ring road
National Highways · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Ambulance crew waiting in corridor due to insufficient clinical space
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 1 coronerIdentical hazardConfidence 0.95 · 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 - Lack of regular first aid training among custodial staff
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of CPR training among carers
Health and Safety Executive · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 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
- 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 0.90 · high
- Adhesions leading to small bowel obstruction
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coronersClosely relatedConfidence 0.90 · high - Unclear wording in NHS Pathways triage questions
NHS England · National body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 2 coronersIdentical hazardConfidence 0.92 · high
- Absence of in-cell automatic fire detection
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high