Repeated warnings
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543 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Inadequate audit of 111 call errors
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 2 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Inadequate supervision and documentation of junior doctors
Greater Manchester Mental Health NHS Foundation Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Incomplete national early warning system scoring
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.85 · high - Lack of clear protocol for repeated 999 calls and non-ambulance response
North East Ambulance Service NHS Foundation Trust · Ambulance service
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Insufficient traffic calming at junction leading to collisions
Lincolnshire County Council · Local authority
4 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Inadequate diabetes screening guidance for healthcare professionals
National Institute for Health and Care Excellence · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo 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 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Inadequate ACCT documentation and healthcare absence during reviews
HMP Woodhill · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Communication failures between mental health liaison team and acute hospital
Brighton and Sussex University Hospitals NHS Trust · NHS body
2 reports · 1 coronerClosely relatedConfidence 0.85 · high - Unnecessary patient transfers without proper documentation
Brighton and Sussex University Hospitals NHS Trust · NHS body
3 reports · 1 coronerClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Excessive speed on b5017 in populated area
Staffordshire County Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate double check in controlled drug audit
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.92 · high - Lack of end-of-day verification of dispensed drugs
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Inconsistent mental health service provision for 16-18 year olds
Department of Health and Social Care · National body
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 - Lack of clear guidance on ligature incidents and self-harm risk
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report