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.
All chains
197 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Unattended blade in cell overnight
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Inadequate transfer of suicide risk information
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Missing mental health assessment in police custody
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - Delays in investigating adverse incidents and implementing actions
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Healthcare staff absent during ACCT reviews
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 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
- Lack of coordinated support for vulnerable adults with complex needs
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- Accessible bridge parapet and railing
Durham County Council · Local authority
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Insufficient mental health resources for children and young people
Department of Health and Social Care · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Unrestricted sale of helium gas canisters
Home Office · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Marac system ineffective for chaotic victims
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high