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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152 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 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 - 5 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Ambulance handover delays due to bed shortages
Welsh Ambulance Service NHS Trust · Ambulance service
10 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Physical health check delays mental health referrals
Norfolk and Suffolk NHS Foundation Trust · NHS body
5 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of regular allergy review and named accountability for allergy services
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Welfare checks missed and undocumented
HMP Swaleside · Prison or detention
3 reports · 1 coronerClosely relatedConfidence 0.90 · high - Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Inadequate clinical records hinder investigations
Department of Health and Social Care · National body
3 reports · 1 coronerIdentical hazardConfidence 0.90 · high - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report