Repeated warnings
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337 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of regular allergy review and named accountability for allergy services
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Misleading packaging resembling sweets leading to ingestion
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Medical information not disclosed to firearms licensing authority
National Police Chiefs' Council · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Incomplete or meaningless ACCT observations in prison
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Critical clinical information lost during verbal handover
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Lack of personal care and health deterioration in domiciliary care
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Recurring hazard (see the quoted concerns)
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Inadequate clinical records hinder investigations
Department of Health and Social Care · National body
3 reports · 1 coronerIdentical hazardConfidence 0.90 · high - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed bespoke care placement arrangements
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Window restrictors fail to prevent opening beyond 100mm
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate