Repeated warnings
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46 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Delay in reporting original x-ray findings to clinicians
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 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 - Inadequate patient handover practices
Welsh Ambulance NHS Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Lack of risk assessment for missing persons
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Ambulance fails to document refusal consent
West Midlands Ambulance Service · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Ambulance resource shortage delays urgent patient transfers
East Midlands Ambulance Service · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Inadequate adrenaline dose in autoinjectors
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - Inadequate audit of 111 call errors
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Petrol based emollient cream fire risk
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Simultaneous ambulance crew meal breaks reduce vehicle availability
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Delayed ambulance dispatch to unconscious head injury patient
East Midlands Ambulance Service · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Insufficient ambulance resources in specific division
East Midlands Ambulance Service · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Patient flow problems leading to ambulance handover delays
Welsh Ambulance Service NHS Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Missing fire hazard warnings on emollient cream packaging
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highReviewed dossier - Ambulance arrival delay due to operational shortages
North East Ambulance Service NHS Foundation Trust · Ambulance service
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Paramedic staffing shortages impacting ambulance response times
North East Ambulance Service NHS Foundation Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.92 · high