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.

Organisation type

Ambulance service25 Commissioner6 Company or provider10 Local authority28 National body342 NHS body175 Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health Products and workplaces9 Roads and rail53 Suicide197 Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:Mental health Closely related Clear all

57 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Lack of assistance for individuals with addictions and mental health difficulty
Change Grow Live · Other
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Absence of smoke alarms in dwelling
Leeds City Council · Local authority
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of continuous family engagement in patient care
Northumberland · Other
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Incomplete patient leave documentation
Lancashire Care NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Misunderstanding of section 135 mental health act powers leading to delays
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Inadequate diabetes screening guidance for healthcare professionals
National Institute for Health and Care Excellence · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Recurring hazard (see the quoted concerns)
Metropolitan Police Service · Police
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Lack of clear guidance on ligature incidents and self-harm risk
Care Quality Commission · National body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of care plan coordination
Care Quality Commission · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Sequential treatment of dual diagnosis
Cornwall NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inadequate record keeping compromising patient safety
Pennine Care NHS Trust · NHS body
3 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of discharge planning in mental health services
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Delay in declaring missing and informing police
Sussex Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incomplete care plan and risk assessment documentation
Sussex Partnership NHS Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Risk assessment not updated after formulation meeting
Tees · Other
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Lack of written observation protocol for child and adolescent mental health unit
Greater Manchester West Mental Health NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Discharge without follow up arrangements
South London and Maudsley NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report

All chains