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
19 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo 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 - 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Ketamine misclassification as Class B drug
Home Office · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - Inconsistent access to thrombectomy services
NHS England · National body
7 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Lack of action on high clozapine blood test results
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Untrained police control room staff lack recognition of acute behaviour
College of Policing · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Look-alike medication packaging leading to dispensing errors
Medicines and Healthcare products Regulatory Agency · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of joint access to NHS records by out of hours services
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate double check in controlled drug audit
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.92 · high - Lack of end-of-day verification of dispensed drugs
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high