Repeated warnings
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666 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Inaccurate ACCT documentation affecting prisoner safety
HM Inspectorate of Prisons · Prison or detention
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate ACCT training leading to incomplete documentation
His Majesty's Prison and Probation Service · National body
16 reports · 15 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inadequate ACCT documentation and communication
Central and North West London NHS Foundation Trust · NHS body
4 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Adhesions leading to small bowel obstruction
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Insufficient patient observation leading to inpatient falls
University Hospitals Birmingham NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Inadequate CAWN risk assessment for young persons
Home Office · National body
2 reports · 2 coronersClosely relatedConfidence 0.70 · moderate - Insufficient awareness of immersion pulmonary oedema risk for high bloodpressure
British Diving Safety Group · Company or provider
2 reports · 2 coronersIdentical hazardConfidence 0.92 · high - Maternal heart rate misinterpreted as fetal heart rate
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - Divers not disclosing health problems during HSE medicals
Health and Safety Executive · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- 2 reports · 2 coronersClosely relatedConfidence 0.92 · high
- Inadequate staff training for fire evacuation in specialist housing
National Fire Chiefs Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Lack of communication between prison healthcare and operational staff
Ministry of Justice · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Inadequate temporary signage at junction
Department for Transport · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 16 reports · 13 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report