Repeated warnings
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342 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Self certification enables unsafe drug access
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Misunderstanding of section 135 mental health act powers leading to delays
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate adrenaline dose in autoinjectors
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Inadequate audit of 111 call errors
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate diabetes screening guidance for healthcare professionals
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Petrol based emollient cream fire risk
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.93 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 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 - Inadequate double check in controlled drug audit
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.92 · high - Lack of end-of-day verification of dispensed drugs
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Inconsistent mental health service provision for 16-18 year olds
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Simultaneous ambulance crew meal breaks reduce vehicle availability
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Lack of clear guidance on ligature incidents and self-harm risk
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of care plan coordination
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of meaningful family involvement in care process
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Inadequate information sharing between mental health and substance misuse teams
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report