Repeated warnings
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At least
39 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of acute mental health inpatient beds
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
5 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.90 · high - Ambulance delays leading to resource unavailability
Betsi Cadwaladr University Health Board · NHS body
12 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 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 - Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Lack of lead practitioner during transfer leading to lost follow up
Sussex Partnership NHS Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.85 · high - Unnecessary patient transfers without proper documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate record keeping and retention compromising care
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.82 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 5 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 3 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Incomplete and inaccurate nursing records and documentation
Pennine Acute Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.85 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate communication between clinical staff and families
Tameside Hospital NHS Foundation Trust · NHS body
4 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of written observation protocol for child and adolescent mental health unit
Greater Manchester West Mental Health NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report