Repeated warnings
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57 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of formal liaison between NHS and private mental health providers
Royal College of Psychiatrists · National body
4 reports · 4 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - Carers not advised of suicide risk behaviours
Kent and Medway NHS and Social Care Partnership Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- 4 reports · 4 coronersClosely relatedConfidence 0.80 · moderate
- Lack of acute mental health inpatient beds
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
5 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Insufficient ambulance resources leading to delayed response
South East Coast Ambulance Service · Ambulance service
4 reports · 3 coronersClosely relatedConfidence 0.85 · high - Missing mental health assessment in police custody
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Insufficient mental health resources for children and young people
Department of Health and Social Care · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - Delayed reporting of missing detained patient
Surrey and Borders Partnership NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Lack of lead practitioner during transfer leading to lost follow up
Sussex Partnership NHS Trust · NHS body
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust · NHS body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate signage and lighting at foot crossing
Network Rail · National body
4 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Missing escort records during reception screening
His Majesty's Prison and Probation Service · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report