Repeated warnings
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163 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of follow-up on mental health history and drug overdose
Practice Plus Group · Company or provider
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 55 reports · 32 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate risk assessment documentation and inaccurate record keeping
Essex Partnership University NHS Foundation Trust · NHS body
6 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 1 coronerClosely relatedConfidence 0.85 · high
- Untrained staff conducting mental health assessments
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.92 · high - Lack of basic first aid training and CPR among prison officers
His Majesty's Prison and Probation Service · National body
12 reports · 12 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier - Inconsistent mental health emergency protocols across police forces
Metropolitan Police Service · Police
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Inadequate weekend mental health provision at prison
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Inaccurate ACCT documentation affecting prisoner safety
HM Inspectorate of Prisons · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate ACCT training leading to incomplete documentation
His Majesty's Prison and Probation Service · National body
16 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate ACCT documentation and communication
Central and North West London NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Lack of communication between prison healthcare and operational staff
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate ACCT case management at HMP Woodhill
HMP Woodhill · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Insufficient inpatient bed capacity leading to delayed discharges and patient harm
Department of Health and Social Care · National body
26 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of mandatory ACCT training for agency staff
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of mandatory first aid and CPR training for prison officers
HMP Pentonville · Prison or detention
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 21 reports · 18 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report