Repeated warnings
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At least
88 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Unrestricted domestic purchase of substance
Home Office · National body
2 reports · 1 coronerIdentical hazardConfidence 0.96 · high - Delayed staff training on cell entry and emergency communications
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 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 - Delayed emergency department treatment due to overcrowding
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high - 3 reports · 3 coronersIdentical hazardConfidence 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 - Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Patients not informed of surgical risks in Turkey
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 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)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inadequate communication of SSRI suicide risk
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.85 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Detention without section due to bed shortage
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Drivers entering slip road wrong direction due to inadequate signage
National Highways · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high - 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
- Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report