Repeated warnings
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349 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delayed ambulance response to critically unwell patient
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Untrained police control room staff lack recognition of acute behaviour
College of Policing · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Lack of integrated multidisciplinary care across sites
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-cool
UK Health Security Agency · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Unattended blade in cell overnight
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate transfer of suicide risk information
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delays in investigating adverse incidents and implementing actions
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Absence of breathing guard during mouth to mouth resuscitation
His Majesty's Prison and Probation Service · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of timely reporting and registration of food allergy fatalities
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inadequate patient handover practices
Welsh Ambulance NHS Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Shortage of emergency department consultants and middle-grade doctors
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - Inadequate training for firearms licensing staff
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Lack of risk assessment for missing persons
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Accessible bridge parapet and railing
Durham County Council · Local authority
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · high