Repeated warnings
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At least
64 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 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 - Missing radiology discussion records for children
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Insufficient complex neonatal resuscitation training
Royal College of Paediatrics and Child Health · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Recurring hazard (see the quoted concerns)
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Insufficient swimming education leading to drowning in open water
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 1 coronerIdentical hazardConfidence 0.98 · highNo published response to an earlier report
- 3 reports · 3 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 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 - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Critical clinical information lost during verbal handover
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Insufficient probation officer staffing creates safety risks
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · 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 - Inadequate street lighting at junction
Warwickshire County Council · Local authority
5 reports · 4 coronersClosely relatedConfidence 0.86 · high - Unsupervised minors and inaccurate attendance data at Leeds Festival
Leeds City Council · Local authority
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Lack of integrated multidisciplinary care across sites
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high