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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At least
57 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 55 reports · 32 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate risk assessment documentation and inaccurate record keeping
Essex Partnership University NHS Foundation Trust · NHS body
6 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 1 coronerClosely relatedConfidence 0.85 · 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 - Inadequate ACCT training leading to incomplete documentation
His Majesty's Prison and Probation Service · National body
16 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate ACCT documentation and communication
Central and North West London NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Insufficient inpatient bed capacity leading to delayed discharges and patient harm
Department of Health and Social Care · National body
26 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of mandatory ACCT training for agency staff
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 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 - 21 reports · 18 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Non‑compliance with care plans and insufficient incident review
Care Quality Commission · National body
5 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of certified safer cells outside segregation unit
His Majesty's Prison and Probation Service · National body
4 reports · 4 coronersClosely relatedConfidence 0.80 · moderate - 5 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Inadequate record keeping leading to outdated patient information
Essex Partnership NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 3 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Public access to live rail at platform end
Network Rail · National body
16 reports · 14 coronersClosely relatedConfidence 0.85 · highReviewed dossier - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report