Repeated warnings
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167 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Insufficient family involvement in mental health care processes
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of mental health service connection by probation officers
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of lead practitioner during transfer leading to lost follow up
Sussex Partnership NHS Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Inadequate risk assessment documentation and undocumented risk disclosures
Ministry of Defence · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Lack of communication and care coordination in placement decisions
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate supervision and documentation of junior doctors
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Inadequate ACCT documentation and healthcare absence during reviews
HMP Woodhill · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · 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 - Lack of meaningful family involvement in care process
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Excessive waiting time for psychotherapy
Tameside and Glossop Clinical Commissioning Group · Commissioner
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Insufficient nighttime staffing leading to missed healthcare involvement in ACCT
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Missing admission risk assessments and care plan details
Avon and Wiltshire Mental Health NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate signage and lighting at foot crossing
Network Rail · National body
4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Unclear hospital transfer process and forms
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Delayed resolution of outstanding safety issues
Avon and Wiltshire Mental Health Partnership NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report