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 health72 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

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

Inappropriate referral to Healthy Minds for complex PTSD
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Young people placed in adult mental health facilities
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate cell sharing risk assessment for epilepsy and sexual orientation
HMP Pentonville · Prison or detention
2 reports · 1 coroner
Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
Lack of contingency planning for patient departure
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Recurring hazard (see the quoted concerns)
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Risk of suicide and self-harm in newly arrived prisoners
His Majesty's Prison and Probation Service · National body
3 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Ambulance response delay in North West
North West Ambulance Service · Ambulance service
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Lack of timely crisis team visits and communication
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Delayed mental health assessment in emergency unit
Camden and Islington NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Inaccurate early warning score calculation by clinical staff
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.80 · moderate
Missing escort records during reception screening
His Majesty's Prison and Probation Service · National body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
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
Inadequate patient information handover between care settings
Manchester Clinical Commissioning Group · Commissioner
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Inadequate clinical record keeping
Department of Health and Social Care · National body
2 reports · 2 coroners
Closely relatedConfidence 0.85 · high
Delayed ambulance arrival due to resource shortages
Welsh Ambulance Trust · Ambulance service
2 reports · 1 coroner
Closely relatedConfidence 0.85 · high
Incomplete nursing records
Stockport NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Risk assessment not updated after formulation meeting
Tees · Other
2 reports · 2 coroners
Closely relatedConfidence 0.85 · highNo published response to an earlier report
Inadequate escalation of clinical care
Gloucestershire Hospitals NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate ACCT document review and agency input documentation
Care UK · Other
3 reports · 3 coroners
Closely relatedConfidence 0.70 · moderate
Inadequate staff training and understanding of ACCT protocol
HMP Pentonville · Prison or detention
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high

All chains