Repeated warnings
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64 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 - Welfare checks missed and undocumented
HMP Swaleside · Prison or detention
3 reports · 1 coronerClosely relatedConfidence 0.90 · 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
- 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 - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Excessive ambulance handover delays at hospitals
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.90 · high - Ambulance delays for frail elderly hip fracture patients
Department of Health and Social Care · National body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed ambulance response to critically unwell patient
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - 4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate audit of observations and documentation
Greater Manchester Mental Health NHS Foundation Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Poor record keeping in missing person investigations
Department of Health and Social Care · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Blind spot behind enclosed goods vehicle
Department for Transport · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Lack of coordinated chronic asthma management
NHS England · National body
3 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report