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 national guidance for antenatal fetal monitoring
Royal College of Obstetricians and Gynaecologists · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Inadequate medical documentation oversight
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Unclear wording in NHS Pathways triage questions
NHS England · National body
3 reports · 2 coronersClosely relatedConfidence 0.90 · high - Young drivers carrying peer passengers increase collision risk
Department for Transport · National body
8 reports · 7 coronersClosely relatedConfidence 0.85 · highReviewed dossier - Delayed or missing clinical observations in pediatric emergency care
Royal College of Paediatrics and Child Health · National body
3 reports · 2 coronersClosely relatedConfidence 0.87 · high - Lack of validated paediatric sepsis screening tool in emergency departments
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Inaccurate post mortem sampling in suspected anaphylaxis cases
Royal College of Pathologists · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Locum registrar without assessment or supervision
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.70 · moderate - Misinterpretation of centile chart guidance leading to delayed recognition of fe
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - Absence of learning disability liaison nurse support
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · high - 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- Inconsistent iv fluid administration and inadequate shock management
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.86 · 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 - 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 - 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)
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
- 3 reports · 3 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