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
72 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Poor record keeping in missing person investigations
Department of Health and Social Care · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - Inadequate seizure recognition and post‑seizure behaviour training
College of Policing · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.95 · 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
- 2 reports · 2 coronersIdentical hazardConfidence 0.95 · highNo published response to an earlier report
- Uncontrolled prescribing of contraindicated drugs
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · 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 - Lack of assistance for individuals with addictions and mental health difficulty
Change Grow Live · Other
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Absence of smoke alarms in dwelling
Leeds City Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate inter-agency communication about risk and urgency
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely 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 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Inadequate diabetes screening guidance for healthcare professionals
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Lack of clear guidance on ligature incidents and self-harm risk
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report