Repeated warnings
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87 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 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
- Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 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 0.85 · high
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Insufficient lighting at pedestrian refuge
National Highways · National body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Overcrowded emergency department leading to delays
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · high - Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine · National body
3 reports · 3 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - 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 - Look-alike medication packaging leading to dispensing errors
Medicines and Healthcare products Regulatory Agency · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Missing mental health assessment in police custody
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - Unlicensed DNP weight loss drug toxicity
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Insufficient mental health resources for children and young people
Department of Health and Social Care · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · 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