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
666 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delayed discharge increases infection risk for frail elderly patients
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Medically fit patients occupying hospital beds leading to ED overcrowding
Department of Health and Social Care · National body
3 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of standard operating procedures for worsening patients in renal unit
Royal Cornwall Hospital · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - 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 - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Shortage of tier 4 paediatric mental health beds
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 21 reports · 18 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate training for police and ambulance crew on acute behavioural distress
Association of Ambulance Chief Executives · Ambulance service
5 reports · 5 coronersClosely relatedConfidence 0.85 · high - Lack of electronic access to primary care medical notes
Department of Health and Social Care · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 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 - Sustained high operational pressure at REAP Level 4
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Insufficient information on gambling risks and unlicensed sites
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inadequate ACCT training and knowledge gaps
Practice Plus Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed ACCT case review and inadequate process management
Practice Plus Group · Company or provider
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate