Repeated warnings

These concerns went to different organisations, so they are not one organisation's chain. They show a hazard that coroners in different places raised again and again. Each later report was judged against the earliest one, with both quotes checked word for word.

• 13 organisationsDelays in patient handover leading to ambulance resource unavailability6 reports · 2014–2026▾

  First raised · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”

  Identical hazardConfidence 0.85 · highPeter Scott ↗

  Both reports identify delayed patient handovers at emergency departments causing prolonged ambulance waits and reduced availability of ambulance resources as a safety risk.

  Earlier · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls.”

  Later · 26 May 2016

  “one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”

  Identical hazardConfidence 0.96 · highRebecca Evans ↗

  Both reports identify the same hazard: prolonged patient handover delays in the Emergency Department causing ambulance backlog and delayed care. The mechanism described—unacceptable delays keeping patients in ambulances and tying up resources—is unchanged.

  Earlier · 21 Jan 2014

  “That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”

  Later · 14 Mar 2017

  “despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls.”

  Identical hazardConfidence 0.95 · highLilly Baxandall ↗

  Both reports identify that poor handover processes in emergency departments cause prolonged ambulance waits, tying up resources.

  Earlier · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods”

  Later · 17 May 2017

  “concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances”

  Identical hazardConfidence 0.96 · highNicola Owens: Prevention of Future Deaths Report ↗

  Both reports identify patient handover delays in emergency departments as causing ambulances to be held up and unavailable for other calls.

  Earlier · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays”

  Later · 31 Jan 2025

  “The delay in an ambulance attending patients due to the unavailability of ambulances.”

  Closely relatedConfidence 0.92 · highRoman Barr: Prevention of future deaths report ↗

  Both reports identify prolonged ambulance handover times as a cause of delayed patient care and reduced emergency resource availability. The later report reiterates this hazard while adding contextual details about demand periods.

  Earlier · 21 Jan 2014

  “the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays”

  Later · 4 Mar 2026

  “Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”

• 10 organisationsLack of clinical observations for 12 hours5 reports · 2014–2025▾

  First raised · 13 Jan 2014

  “There was a lack of clinical observations for a period of 12 hours on the 9th December. In addition no nursing observations were carried out during this period of time.”

  Closely relatedConfidence 0.80 · moderateNeil Carter ↗

  Both reports highlight insufficient nursing observations as a safety concern. They also note staffing and communication shortcomings contributing to the observation gaps.

  Earlier · 13 Jan 2014

  “lack of clinical observations for a period of 12 hours”

  Later · 5 Mar 2014

  “There were repeated failures to perform basic nursing observations”

  Closely relatedConfidence 0.85 · highAgnes Hannan ↗

  Both reports highlight failures in maintaining adequate patient records and communication, which can lead to missed clinical information and delayed interventions.

  Earlier · 13 Jan 2014

  “There was a lack of clinical observations for a period of 12 hours on the 9th December.”

  Later · 27 Oct 2014

  “There was an actual, or perceived, lack of availability of the hospital notes and records of previous diagnoses and treatments”

  Closely relatedConfidence 0.85 · highDavid Hughes ↗

  Both reports highlight failures in conducting required patient observations at appropriate intervals. The underlying hazard is inadequate monitoring leading to missed clinical deterioration.

  Earlier · 13 Jan 2014

  “There was a lack of clinical observations for a period of 12 hours on the 9th December.”

  Later · 9 Feb 2016

  “Level 2 observations were not conducted at the prescribed time intervals and periods of up to two hours lapsed between observations”

  Closely relatedConfidence 0.88 · highAlan Horrocks: Prevention of future deaths report ↗

  Both reports describe failures to perform required patient observations and to act on abnormal scores, delaying detection of clinical deterioration.

  Earlier · 13 Jan 2014

  “There was a lack of clinical observations for a period of 12 hours on the 9th December.”

  Later · 28 Oct 2025

  “observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance”

• 8 organisationsLack of awareness among healthcare professionals about fire risk of emollients3 reports · 2018–2025▾

  First raised · 29 May 2018

  “e Health care professionals in both hospital and community setting may not be aware of the potential fire hazard poised by emollient creams which contain a low level of paraffin”

  Closely relatedConfidence 0.90 · highPauline Allison: Prevention of future deaths report ↗

  Both reports identify paraffin‑based emollient creams as a fire hazard due to their flammable ingredients. The later report elaborates on how the residue accumulates on fabrics and how equipment like air mattresses can worsen ignition.

  Earlier · 29 May 2018

  “Paraffin based ointments and emollient creams which contain a low level of paraffin pose a potential fire hazard risk”

  Later · 3 Aug 2021

  “emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding.”

  Closely relatedConfidence 0.90 · highJames Rownsley: Prevention of future deaths report ↗

  Both reports identify paraffin‑based emollient creams as a fire hazard when exposed to flames or heat. They highlight the need for better awareness and communication about this risk.

  Earlier · 29 May 2018

  “Paraffin based ointments and emollient creams which contain a low level of paraffin pose a potential fire hazard risk”

  Later · 12 Aug 2025

  “The need for effective communication to partners and stakeholders responsible for either prescribing such emollients, or indeed caring for people in the community, of the dangers of using such creams particularly when in close proximity to flames or heat.”

• 6 organisationsInsufficient mental health bed capacity4 reports · 2024–2026▾

  First raised · 11 Jun 2024

  “bed capacity remains an ongoing problem and has not been resolved”

  Closely relatedConfidence 0.90 · highMatthew Sheldrick (1): Prevention of Future Deaths Report ↗

  Both reports identify a shortage of mental health inpatient beds as causing excessively long waits in emergency departments. This bed shortage creates a risk of harm to patients awaiting appropriate care.

  Earlier · 11 Jun 2024

  “no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.”

  Later · 16 Dec 2024

  “The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting beds.”

  Closely relatedConfidence 0.82 · moderateMatthew Sheldrick (2): Prevention of Future Deaths Report ↗

  Both reports identify insufficient mental‑health inpatient bed provision as creating prolonged emergency department stays for people in crisis.

  Earlier · 11 Jun 2024

  “Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.”

  Later · 16 Dec 2024

  “There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”

  Closely relatedConfidence 0.88 · highMartin Bryant: Prevention of future deaths report ↗

  Both reports highlight insufficient mental health bed availability leading to prolonged waits for admission.

  Earlier · 11 Jun 2024

  “bed capacity in London remains inadequate.”

  Later · 19 Jan 2026

  “The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.”

• 5 organisationsDelay in ambulance response3 reports · 2015–2018▾

  First raised · 31 Mar 2015

  “There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed”

  Identical hazardConfidence 0.90 · highHayden Norton ↗

  Both reports identify a delay in summoning an emergency ambulance due to the absence or non‑use of a proper emergency code/protocol.

  Earlier · 31 Mar 2015

  “There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed.”

  Later · 13 Apr 2015

  “There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.”

  Identical hazardConfidence 0.90 · highJohn O'Meara ↗

  Both reports describe a delay in summoning emergency assistance because prison staff did not follow the established code‑blue/red activation procedure. This failure creates a risk of preventable deaths.

  Earlier · 31 Mar 2015

  “There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed.”

  Later · 10 Jan 2018

  “| am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called.”

• 4 organisationsPremature closure of ACCT3 reports · 2016–2026▾

  First raised · 20 Sept 2016

  “This ACCT was only open for a short period. It did not serve [the deceased]'s needs properly and was closed before any review system picked up the inadequacies.”

  Closely relatedConfidence 0.80 · moderateSean Higgins: Prevention of Future Deaths Report ↗

  Both reports highlight failures in completing and reviewing required documentation during ACCT assessments, which undermines accurate risk evaluation.

  Earlier · 20 Sept 2016

  “The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have”

  Later · 11 Mar 2025

  “some officers chairing reviews did not read relevant documentation beyond the last ACCT review prior to the review taking place”

  Closely relatedConfidence 0.85 · highRickie Poon: Prevention of future deaths report ↗

  Both reports identify shortcomings in the ACCT assessment process, such as incomplete documentation and inconsistent supervision during reviews.

  Earlier · 20 Sept 2016

  “The ACCT document was not completed fully, did not accompany [the deceased] around the prison as it should have”

  Later · 4 Jan 2026

  “- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”

• 4 organisationsContinuing ambulance delays3 reports · 2023–2025▾

  First raised · 20 Jun 2023

  “I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.”

  Closely relatedConfidence 0.80 · moderateJean Frickel: Prevention of future deaths report ↗

  Both reports highlight delays in ambulance availability as a safety concern. The earlier report focuses on prolonged response and handover times, while the later report links delays to patient flow bottlenecks caused by social‑care shortages.

  Earlier · 20 Jun 2023

  “Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later.”

  Later · 21 Jun 2023

  “It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department”

  Closely relatedConfidence 0.92 · highJeanette Sidlow Beech: Prevention of Future Deaths Report ↗

  Both reports highlight prolonged ambulance-related delays—waiting for arrival or handover—that can lead to preventable harm. The underlying hazard is systemic delay in emergency medical response.

  Earlier · 20 Jun 2023

  “On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”

  Later · 29 May 2025

  “It took a total period of 15 hours and 13 minutes for an ambulance to attend upon [the deceased], by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.”

• 3 organisationsUnmonitored residents3 reports · 2023–2026▾

  First raised · 26 Apr 2023

  “no carer was in the lounge area monitoring the residents”

  Closely relatedConfidence 0.80 · moderateEdith Alden: Prevention of future deaths report ↗

  Both reports identify inadequate supervision of residents as a key factor contributing to preventable falls. They highlight that insufficient staff presence or unclear responsibilities leave high‑risk individuals unwatched, increasing fall risk.

  Earlier · 26 Apr 2023

  “no carer was in the lounge area monitoring the residents. Accordingly, when Mrs [name redacted] left the lounge area she was not monitored as required.”

  Later · 16 Apr 2024

  “Residents deemed as at very high risk of falls were, and still are, allowed in communal areas with no carer present.”

  Identical hazardConfidence 0.90 · highPatricia Barnett: Prevention of future deaths report ↗

  Both reports identify the hazard of residents being left unsupervised in the lounge area, which increases the risk of falls and potential death.

  Earlier · 26 Apr 2023

  “Accordingly, when Mrs [name redacted] left the lounge area she was not monitored as required.”

  Later · 21 May 2026

  “I am concerned that Mrs [name redacted] was left unsupervised in the lounge area.”

• 3 organisationsRecurring hazard (see the quoted concerns)3 reports · 2016–2019▾

  First raised · 6 May 2016

  “when the monitoring equipment alarmed this did not result in senior staff attending”

  Closely relatedConfidence 0.80 · moderateJames O'Brien ↗

  Both reports highlight shortcomings in staff preparedness and response during patient deterioration. They each point to gaps in training, communication, or familiarity that hindered timely intervention.

  Earlier · 6 May 2016

  “The level of competence and training of staff working in the Acute Assessment Unit with regard to the use of NEW Score system and communication between all levels of staff.”

  Later · 13 Mar 2017

  “(7) There was a failure to ensure that staff were adequately trained to respond to an emergency situation.”

  Closely relatedConfidence 0.80 · moderateRobert Lowe ↗

  Both reports highlight failures where audible alarms do not lead to appropriate staff response.

  Earlier · 6 May 2016

  “when the monitoring equipment alarmed this did not result in senior staff attending.”

  Later · 20 Sept 2019

  “important audible alarms may not come to the attention of staff.”

• 3 organisationsLack of communication between agencies3 reports · 2015–2023▾

  First raised · 19 Feb 2015

  “There was a lack of communication between the Partnership Trust and other agencies”

  Closely relatedConfidence 0.85 · highGrant Burns ↗

  Both reports identify insufficient communication among involved agencies as a contributing factor. The later report specifies the agencies involved while the earlier notes a missing care‑coordinator role.

  Earlier · 19 Feb 2015

  “There was a lack of communication between the Partnership Trust and other agencies.”

  Later · 23 Feb 2017

  “(3) There was a lack of communication between partner agencies”

  Closely relatedConfidence 0.85 · highMark McKessy: Prevention of future deaths report ↗

  Both reports highlight inadequate communication and information sharing among agencies leading to fragmented care. The later report adds concerns about unrecognised health needs but centres on the same coordination failure.

  Earlier · 19 Feb 2015

  “There was a lack of communication between the Partnership Trust and other agencies.”

  Later · 9 Oct 2023

  “Poor communication/information sharing between agencies which meant that there was no coordination of care”