Repeated warnings
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20 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Unclear wording in NHS Pathways triage questions
NHS England · National body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inaccurate post mortem sampling in suspected anaphylaxis cases
Royal College of Pathologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Absence of learning disability liaison nurse support
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · high - 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- Inconsistent interpretation of antenatal CTG leading to delayed response
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Insufficient complex neonatal resuscitation training
Royal College of Paediatrics and Child Health · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - Recurring hazard (see the quoted concerns)
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of regular allergy review
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 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 - Lack of residential substance misuse treatment for under 18
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Insufficient school nurse staffing weakens health education link
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 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 - Inadequate training for firearms licensing staff
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of public access to adrenaline auto-injectors
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - High‑risk offenders placed in unsuitable supported living accommodation
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Lack of coordinated chronic asthma management
NHS England · National body
3 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - Inadequate face to face medical handover of patient information
Care Quality Commission · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Inconsistent antenatal CTG interpretation leading to delayed response
Royal College of Obstetricians and Gynaecologists · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of antenatal screening for group B streptococcus
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high