Repeated warnings
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193 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Online suicide method guides and forums
Department for Science · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Lack of medication monitoring after clinic visit
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Incorrect section placement and missing information during assessments
Birmingham City Council · Local authority
3 reports · 1 coronerClosely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of mental capacity assessment and risk assessment in emergency settings
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inability to access GP medication records across systems
Essex Partnership University NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of information sharing between online prescribing services and GP systems
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed community offender manager engagement before release
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Inadequate communication of SSRI suicide risk
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 5 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report