Repeated warnings
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202 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 5 reports · 5 coronersClosely relatedConfidence 0.90 · high
- Lack of staff training in cardiac arrest recognition and first aid
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Delayed emergency department treatment due to overcrowding
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high - Inadequate english proficiency hindering communication and safety
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- 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 - 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 - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Patients not informed of surgical risks in Turkey
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 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)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Lack of information sharing between online prescribing services and GP systems
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high