Repeated warnings

All chains

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

• Inadequate record keeping of claimant interactions

  Department for Work and Pensions · National body

  2 reports · 2 coroners

  20212024
  Closely relatedConfidence 0.90 · high
• Easy access to suicide instructions online and in print

  Department for Culture · National body

  2 reports · 2 coroners

  20242024
  Closely relatedConfidence 0.90 · highNo published response to an earlier report
• Pedestrians crossing uncontrolled near bus stops

  Department for Transport · National body

  2 reports · 2 coroners

  20202024
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Insufficient anticoagulation guidance for immobilised patients

  National Institute for Health and Care Excellence · National body

  2 reports · 1 coroner

  20232024
  Closely relatedConfidence 0.85 · high
• Lack of GP awareness of prescribed medication

  NHS England · National body

  3 reports · 3 coroners

  20162024
  Closely relatedConfidence 0.90 · high
• Lack of clear protocol for managing sickle cell crises in prisons

  NHS England · National body

  2 reports · 2 coroners

  20142024
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT

  Home Office · National body

  3 reports · 3 coroners

  20192024
  Closely relatedConfidence 0.90 · high
• Inadequate clinical documentation of patient condition and decisions

  Department of Health and Social Care · National body

  2 reports · 2 coroners

  20202024
  Closely relatedConfidence 0.90 · high
• Inadequate out-of-hours psychiatric response and unsuitable section 136 suite

  NHS England · National body

  2 reports · 2 coroners

  20242024
  Closely relatedConfidence 0.85 · high
• Limited placement options for autistic young adults at risk of self-harm or harming others

  NHS England · National body

  2 reports · 2 coroners

  20232024
  Closely relatedConfidence 0.85 · highNo published response to an earlier report
• Call handlers lack clinical training and rely on protocols

  NHS England · National body

  2 reports · 2 coroners

  20172024
  Closely relatedConfidence 0.90 · high
• Long waiting times for psychological assessment

  Department of Health and Social Care · National body

  2 reports · 2 coroners

  20172024
  Closely relatedConfidence 0.90 · high
• Recurring hazard (see the quoted concerns)

  NHS England · National body

  2 reports · 2 coroners

  20242024
  Closely relatedConfidence 0.90 · high
• Insufficient swimming education leading to drowning in open water

  Department for Education · National body

  2 reports · 2 coroners

  20182024
  Closely relatedConfidence 0.85 · high
• Abdominal pain pathway lacks clear discriminatory criteria

  NHS England · National body

  2 reports · 2 coroners

  20212024
  Closely relatedConfidence 0.90 · high
• Detention without section due to bed shortage

  NHS England · National body

  2 reports · 2 coroners

  20232024
  Identical hazardConfidence 0.90 · highNo published response to an earlier report
• Delayed on-call consultant response to night emergencies

  NHS England · National body

  3 reports · 3 coroners

  20182024
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Missing road markings and signage at junction

  National Highways · National body

  2 reports · 2 coroners

  20172024
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Drivers entering slip road wrong direction due to inadequate signage

  National Highways · National body

  2 reports · 1 coroner

  20232024
  Identical hazardConfidence 0.90 · high
• Lack of regular allergy review

  NHS England · National body

  2 reports · 2 coroners

  20242024
  Closely relatedConfidence 0.90 · highNo published response to an earlier report