Repeated warnings
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543 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of action on high clozapine blood test results
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Ambulance delays leading to resource unavailability
Betsi Cadwaladr University Health Board · NHS body
12 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Delayed ambulance response to critically unwell patient
Welsh Ambulance Service NHS Trust · Ambulance service
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Lack of integrated multidisciplinary care across sites
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-cool
UK Health Security Agency · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 4 reports · 4 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 - Unattended blade in cell overnight
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Look-alike medication packaging leading to dispensing errors
Medicines and Healthcare products Regulatory Agency · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Inadequate transfer of suicide risk information
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Missing mental health assessment in police custody
NHS England · National body
4 reports · 4 coronersClosely relatedConfidence 0.85 · high - Delays in investigating adverse incidents and implementing actions
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Absence of breathing guard during mouth to mouth resuscitation
His Majesty's Prison and Probation Service · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report - 4 reports · 3 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Healthcare staff absent during ACCT reviews
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate