Repeated warnings
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41 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 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 - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Lack of timely reporting and registration of food allergy fatalities
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inadequate training for firearms licensing staff
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Absence of cardiotocography monitoring in maternity settings
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Lack of public access to adrenaline auto-injectors
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 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 allergy action plan communication in school
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.88 · high - Lack of coordinated chronic asthma management
NHS England · National body
3 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - Inadequate face to face medical handover of patient information
Care Quality Commission · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Young people placed in adult mental health facilities
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Inconsistent antenatal CTG interpretation leading to delayed response
Royal College of Obstetricians and Gynaecologists · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Foreign conviction information not shared on arrest
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report