Repeated warnings
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543 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Shortage of autism-specific crisis care services
NHS England · National body
6 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Misinterpretation of CTG traces leading to missed abnormal fetal heart rate
Royal College of Obstetricians and Gynaecologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of discharge plan responsibility and unclear care coordinator allocation
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Online suicide method guides and forums
Department for Science · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Online suicide forums and self-harm facilitation sites
Ofcom · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Discharge without surgical review or sepsis recognition
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Lack of medication monitoring after clinic visit
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Incorrect section placement and missing information during assessments
Birmingham City Council · Local authority
3 reports · 1 coronerClosely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 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 - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of mental capacity assessment and risk assessment in emergency settings
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Insufficient ambulance availability leading to delayed response
Department of Health and Social Care · National body
7 reports · 7 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 7 reports · 7 coronersClosely relatedConfidence 0.80 · moderateReviewed dossier