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
57 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Inappropriate triage coding delays mental health ambulance response
Association of Ambulance Chief Executives · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate out-of-hours psychiatric response and unsuitable section 136 suite
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of audit and standard care plan implementation
The Priory Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.90 · high - Unlicensed DNP weight loss drug toxicity
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Inadequate audit of observations and documentation
Greater Manchester Mental Health NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inadequate seizure recognition and post‑seizure behaviour training
College of Policing · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Premature discharge from community mental health services
Kernow Clinical Commissioning Group · Commissioner
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Manipulable medication suitability questionnaire
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Delayed ACCT case review and documentation failure
HMP Hewell · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate staff knowledge of pressure sore prevention and equipment use
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high