Repeated warnings
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At least
137 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - Incompatible IT systems hinder information sharing
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- 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 - 3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 6 reports · 5 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Delayed ambulance response due to missed urgency recognition
North East Ambulance Service NHS Foundation Trust · Ambulance service
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Insufficient ambulance availability leading to delayed emergency response
East of England Ambulance Service · Ambulance service
6 reports · 6 coronersClosely relatedConfidence 0.80 · moderate - Insufficient lighting at pedestrian refuge
National Highways · National body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · high
- Overcrowded emergency department leading to delays
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · 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 - Excessive ambulance handover delays at hospitals
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Inadequate street lighting at junction
Warwickshire County Council · Local authority
5 reports · 4 coronersClosely relatedConfidence 0.86 · high - Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine · National body
3 reports · 3 coronersClosely relatedConfidence 0.86 · highNo published response to an earlier report - Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.90 · high - Ambulance delays for frail elderly hip fracture patients
Department of Health and Social Care · National body
3 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report