Repeated warnings
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At least
349 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 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
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Unrecognised oesophageal intubation and unconfirmed tracheal tube placement
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Delayed sepsis recognition and treatment
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 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 - 2 reports · 2 coronersClosely relatedConfidence 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 - 2 reports · 1 coronerClosely 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 - Lack of communication between specialties and roles
Manchester University NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Lack of post discharge support for high risk patients
Leicestershire Partnership NHS Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.90 · 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 - Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high