Repeated warnings

All chains

533 chains, most recent report first. The order is by date only; there is no ranking of organisations.

• Pedestrians crossing unlit dual carriageway at 60mph speed limit

  Durham County Council · Local authority

  2 reports · 2 coroners

  20192020
  Closely relatedConfidence 0.80 · moderate
• Drivers with dementia continue driving unsafely

  Department for Transport · National body

  2 reports · 2 coroners

  20142020
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Lack of communication and care coordination in placement decisions

  Greater Manchester Mental Health NHS Foundation Trust · NHS body

  2 reports · 1 coroner

  20192020
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Inadequate nighttime staffing for dementia residents

  Care Quality Commission · National body

  2 reports · 2 coroners

  20132020
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Unaccounted controlled drugs in care home administration

  Care Quality Commission · National body

  3 reports · 3 coroners

  20142020
  Closely 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 coroners

  20142020
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Pedestrians crossing carriageway without protection

  Transport for London · Other

  3 reports · 3 coroners

  20152020
  Closely relatedConfidence 0.80 · moderate
• Inadequate street lighting creating dark areas

  Department for Transport · National body

  2 reports · 2 coroners

  20152020
  Closely relatedConfidence 0.90 · highNo published response to an earlier report
• Missing pedestrian crossing at busy crossroads

  Transport for London · Other

  2 reports · 2 coroners

  20172020
  Closely relatedConfidence 0.80 · moderate
• Incomplete patient leave documentation

  Lancashire Care NHS Foundation Trust · NHS body

  2 reports · 2 coroners

  20182020
  Closely relatedConfidence 0.90 · high
• Ambulance resource shortage delays urgent patient transfers

  East Midlands Ambulance Service · Ambulance service

  2 reports · 2 coroners

  20162020
  Closely relatedConfidence 0.90 · high
• Misunderstanding of section 135 mental health act powers leading to delays

  Department of Health and Social Care · National body

  2 reports · 2 coroners

  20192020
  Closely relatedConfidence 0.80 · moderate
• Inadequate audit of 111 call errors

  NHS England · National body

  2 reports · 2 coroners

  20142020
  Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
• Lack of internal review and investigation shortcomings

  Manchester Mental Health NHS Trust · NHS body

  2 reports · 1 coroner

  20192019
  Closely 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 coroner

  20132019
  Closely relatedConfidence 0.80 · moderate
• Lack of formal mental health act assessment

  Norfolk and Suffolk NHS Foundation Trust · NHS body

  2 reports · 2 coroners

  20192019
  Closely relatedConfidence 0.80 · moderate
• Incomplete national early warning system scoring

  Brighton and Sussex University Hospitals NHS Trust · NHS body

  3 reports · 1 coroner

  20152019
  Closely relatedConfidence 0.85 · high
• Lack of clear protocol for repeated 999 calls and non-ambulance response

  North East Ambulance Service NHS Foundation Trust · Ambulance service

  2 reports · 2 coroners

  20172019
  Closely relatedConfidence 0.90 · high
• Insufficient traffic calming at junction leading to collisions

  Lincolnshire County Council · Local authority

  4 reports · 3 coroners

  20162019
  Closely relatedConfidence 0.85 · highNo published response to an earlier report
• Inadequate diabetes screening guidance for healthcare professionals

  National Institute for Health and Care Excellence · National body

  2 reports · 2 coroners

  20152019
  Closely relatedConfidence 0.90 · highNo published response to an earlier report