NHS England
548
reports received
153
with a published response found
69
recurrence chains
199
reports in those chains
- Delayed referral for neurosurgical care
NHS England · National body
2 reports · 2 coroners · 2017–2026Closely relatedConfidence 0.90 · high - Inadequate medical documentation oversight
NHS England · National body
2 reports · 2 coroners · 2024–2026Closely relatedConfidence 0.80 · moderate - 3 reports · 1 coroner · 2024–2026Identical hazardConfidence 0.95 · high
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
NHS England · National body
3 reports · 3 coroners · 2015–2026Closely relatedConfidence 0.90 · highNo published response to an earlier report - Inadequate weekend mental health provision at prison
NHS England · National body
3 reports · 3 coroners · 2016–2026Closely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coroners · 2024–2026Closely relatedConfidence 0.90 · high
- Adhesions leading to small bowel obstruction
NHS England · National body
2 reports · 2 coroners · 2024–2026Identical hazardConfidence 0.90 · high - 2 reports · 2 coroners · 2025–2026Closely relatedConfidence 0.85 · high
- 2 reports · 2 coroners · 2019–2026Closely relatedConfidence 0.80 · moderate
- 16 reports · 13 coroners · 2016–2026Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Unclear wording in NHS Pathways triage questions
NHS England · National body
3 reports · 2 coroners · 2019–2026Closely relatedConfidence 0.90 · high - Lack of mandatory ACCT training for agency staff
NHS England · National body
4 reports · 4 coroners · 2017–2026Closely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of validated paediatric sepsis screening tool in emergency departments
NHS England · National body
2 reports · 2 coroners · 2015–2026Closely relatedConfidence 0.85 · high - 2 reports · 2 coroners · 2022–2026Closely relatedConfidence 0.90 · highNo published response to an earlier report
- Shortage of tier 4 paediatric mental health beds
NHS England · National body
2 reports · 2 coroners · 2023–2026Identical hazardConfidence 0.90 · high - 21 reports · 18 coroners · 2014–2026Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 2 reports · 2 coroners · 2019–2026Identical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coroners · 2023–2025Identical hazardConfidence 0.92 · highNo published response to an earlier report
- Inadequate medical information transfer between custodial healthcare providers
NHS England · National body
2 reports · 2 coroners · 2019–2025Closely relatedConfidence 0.85 · high - 5 reports · 5 coroners · 2021–2025Closely relatedConfidence 0.90 · highNo published response to an earlier reportReviewed dossier
- 2 reports · 2 coroners · 2020–2025Identical hazardConfidence 0.92 · highNo published response to an earlier report
- 2 reports · 1 coroner · 2024–2025Identical hazardConfidence 0.96 · high
- Inconsistent access to thrombectomy services
NHS England · National body
7 reports · 6 coroners · 2020–2025Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - 4 reports · 4 coroners · 2018–2025Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Shortage of autism-specific crisis care services
NHS England · National body
6 reports · 6 coroners · 2020–2025Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 2 coroners · 2019–2025Closely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of naloxone availability and training in prisons
NHS England · National body
2 reports · 2 coroners · 2019–2025Closely relatedConfidence 0.90 · highNo published response to an earlier report - Restricted smoking options increase self-harm risk
NHS England · National body
2 reports · 2 coroners · 2019–2024Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coroners · 2016–2024Closely relatedConfidence 0.90 · high - 2 reports · 2 coroners · 2014–2024Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate out-of-hours psychiatric response and unsuitable section 136 suite
NHS England · National body
2 reports · 2 coroners · 2024–2024Closely relatedConfidence 0.85 · high - Limited placement options for autistic young adults at risk of self-harm or harming others
NHS England · National body
2 reports · 2 coroners · 2023–2024Closely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coroners · 2017–2024Closely relatedConfidence 0.90 · high
- Recurring hazard (see the quoted concerns)
NHS England · National body
2 reports · 2 coroners · 2024–2024Closely relatedConfidence 0.90 · high - 2 reports · 2 coroners · 2021–2024Closely relatedConfidence 0.90 · high
- Detention without section due to bed shortage
NHS England · National body
2 reports · 2 coroners · 2023–2024Identical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coroners · 2018–2024Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of regular allergy review
NHS England · National body
2 reports · 2 coroners · 2024–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report - Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coroners · 2017–2024Identical hazardConfidence 0.90 · high - Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coroners · 2019–2024Closely relatedConfidence 0.80 · moderate - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coroners · 2017–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed bespoke care placement arrangements
NHS England · National body
2 reports · 2 coroners · 2023–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report - Incomplete paperwork and missing responsible clinician for section 5(2) holds
NHS England · National body
2 reports · 2 coroners · 2022–2024Closely relatedConfidence 0.85 · high - Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coroner · 2023–2024Identical hazardConfidence 0.95 · high - Delay in obtaining timely imaging reports
NHS England · National body
2 reports · 1 coroner · 2023–2024Closely relatedConfidence 0.80 · moderate - 2 reports · 2 coroners · 2023–2024Closely relatedConfidence 0.90 · high
- Delayed surgery beyond 36 hours
NHS England · National body
2 reports · 2 coroners · 2022–2023Closely relatedConfidence 0.80 · moderate - Lack of automated medication compliance alerts
NHS England · National body
2 reports · 2 coroners · 2015–2023Identical hazardConfidence 0.92 · highNo published response to an earlier report - Absence of fitness to transfer assessment
NHS England · National body
2 reports · 2 coroners · 2014–2023Identical hazardConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coroner · 2022–2023Closely relatedConfidence 0.80 · moderate
- 2 reports · 2 coroners · 2019–2023Identical hazardConfidence 0.90 · high
- Missing mental health assessment in police custody
NHS England · National body
4 reports · 4 coroners · 2017–2023Closely relatedConfidence 0.85 · high - 2 reports · 2 coroners · 2014–2023Closely relatedConfidence 0.80 · moderate
- 2 reports · 2 coroners · 2021–2023Closely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coroners · 2021–2021Identical hazardConfidence 0.95 · high
- Manipulable medication suitability questionnaire
NHS England · National body
2 reports · 2 coroners · 2018–2021Closely relatedConfidence 0.80 · moderate - Uncontrolled prescribing of contraindicated drugs
NHS England · National body
2 reports · 2 coroners · 2014–2021Identical hazardConfidence 0.95 · high - Cancellation of hospital appointments for prisoners
NHS England · National body
2 reports · 2 coroners · 2019–2021Identical hazardConfidence 0.90 · high - Incomplete patient transfer information
NHS England · National body
2 reports · 1 coroner · 2020–2020Closely relatedConfidence 0.85 · high - 2 reports · 2 coroners · 2018–2020Identical hazardConfidence 0.90 · highNo published response to an earlier report
- Self certification enables unsafe drug access
NHS England · National body
2 reports · 2 coroners · 2018–2020Identical hazardConfidence 0.96 · high - Inadequate audit of 111 call errors
NHS England · National body
2 reports · 2 coroners · 2014–2020Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of end-of-day verification of dispensed drugs
NHS England · National body
2 reports · 2 coroners · 2014–2019Closely relatedConfidence 0.85 · high - Inadequate double check in controlled drug audit
NHS England · National body
2 reports · 2 coroners · 2017–2019Closely relatedConfidence 0.92 · high - Lack of meaningful family involvement in care process
NHS England · National body
2 reports · 2 coroners · 2017–2019Closely relatedConfidence 0.90 · high - Inadequate information sharing between mental health and substance misuse teams
NHS England · National body
2 reports · 2 coroners · 2016–2019Identical hazardConfidence 0.92 · highNo published response to an earlier report - Inaccurate discharge letters to primary care
NHS England · National body
2 reports · 2 coroners · 2016–2019Closely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of coordinated chronic asthma management
NHS England · National body
3 reports · 2 coroners · 2015–2019Identical hazardConfidence 0.92 · highNo published response to an earlier report - Unclear hospital transfer process and forms
NHS England · National body
2 reports · 2 coroners · 2017–2017Closely relatedConfidence 0.80 · moderate