Repeated warnings
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202 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Misleading packaging resembling sweets leading to ingestion
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Incomplete or meaningless ACCT observations in prison
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Recurring hazard (see the quoted concerns)
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Inadequate clinical records hinder investigations
Department of Health and Social Care · National body
3 reports · 1 coronerIdentical hazardConfidence 0.90 · high - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed bespoke care placement arrangements
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Window restrictors fail to prevent opening beyond 100mm
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Delayed mental health bed allocation leading to patient deterioration
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Lack of knowledge about emergency response codes and delayed staff training on
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of residential substance misuse treatment for under 18
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Unrecognised acute illness in resident
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Insufficient school nurse staffing weakens health education link
Department for Education · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report